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1.  Risk of exposure to HIV differs according to catechol-o-methyltransferase Val158Met genotype 
AIDS (London, England)  2013;27(11):1779-1782.
The Met allele of the catechol-o-methyltransferase (COMT) Val158Met polymorphism is associated with increased cortical dopamine and risk behaviors including illicit drug use and unprotected sex. Therefore, we examined whether or not the distribution of the Val158Met genotype differed between HIV-infected and HIV-uninfected women. We conducted an Armitage-Cochran Test and logistic regression to compare genotype frequencies between 1,848 HIV-infected and 612 HIV-uninfected women from the Women’s Interagency HIV Study (WIHS). The likelihood of carrying one or two Met alleles was greater in HIV-infected women (61%) compared to HIV-uninfected women (54%), Z = −3.60, p < 0.001. We report the novel finding of an association between the Val158Met genotype and HIV serostatus that may be mediated through the impact of dopamine function on propensity for risk-taking.
doi:10.1097/QAD.0b013e328361c6a1
PMCID: PMC3897122  PMID: 23807274
2.  The HIV prevention needs of injection drug users in Estonia 
Summary
To assess the relationships between HIV transmission risk behaviours, HIV serostatus and knowledge of HIV serostatus among active injection drug users (IDUs) residing in Tallinn, Estonia, we conducted HIV testing and administered a standardized interview to 266 participants reporting recent injection drug use. In total, 45% were HIV positive, and of those, 39% knew their HIV serostatus. Those who knew their HIV-positive serostatus were less likely to report giving someone else their needle after they used it (9%) than were HIV-negative participants (23%) and those who were HIV positive but unaware of their HIV-positive serostatus (25%). There were no statistically significant differences in unprotected sex or other drug use behaviours between the groups. Most participants reported that HIV can be transmitted through sharing needles (98%) and unprotected sexual activity (93%). Prevention needs of IDUs in this area include increasing the rates of HIV testing and implementing effective programmes to reduce sexual and drug use risk behaviours.
doi:10.1258/095646207781024900
PMCID: PMC2925653  PMID: 17609027
HIV; substance abuse; intravenous; sexual behaviour; Baltic states
3.  A Low-Effort, Clinic-Wide Intervention Improves Attendance for HIV Primary Care 
Data from 6 human immunodeficiency virus clinics showed improvements in clinic attendance after versus before a clinic-wide intervention (7% on short-term measure; 3% on longer-term measure). Several subgroups showed larger improvements: younger patients, new or reengaging patients, and patients with elevated viral loads.
Background. Retention in care for human immunodeficiency virus (HIV)–infected patients is a National HIV/AIDS Strategy priority. We hypothesized that retention could be improved with coordinated messages to encourage patients' clinic attendance. We report here the results of the first phase of the Centers for Disease Control and Prevention/Health Resources and Services Administration Retention in Care project.
Methods. Six HIV-specialty clinics participated in a cross-sectionally sampled pretest-posttest evaluation of brochures, posters, and messages that conveyed the importance of regular clinic attendance. 10 018 patients in 2008–2009 (preintervention period) and 11 039 patients in 2009–2010 (intervention period) were followed up for clinic attendance. Outcome variables were the percentage of patients who kept 2 consecutive primary care visits and the mean proportion of all primary care visits kept. Stratification variables were: new, reengaging, and active patients, HIV RNA viral load, CD4 cell count, age, sex, race or ethnicity, risk group, number of scheduled visits, and clinic site. Data were analyzed by multivariable log-binomial and linear models using generalized estimation equation methods.
Results. Clinic attendance for primary care was significantly higher in the intervention versus preintervention year. Overall relative improvement was 7.0% for keeping 2 consecutive visits and 3.0% for the mean proportion of all visits kept (P < .0001). Larger relative improvement for both outcomes was observed for new or reengaging patients, young patients and patients with elevated viral loads. Improved attendance among the new or reengaging patients was consistent across the 6 clinics, and less consistent across clinics for active patients.
Conclusion. Targeted messages on staying in care, which were delivered at minimal effort and cost, improved clinic attendance, especially for new or reengaging patients, young patients, and those with elevated viral loads.
doi:10.1093/cid/cis623
PMCID: PMC3657526  PMID: 22828593
4.  Trends in Contraceptive Use Among Women With Human Immunodeficiency Virus 
Obstetrics and gynecology  2012;120(4):783-790.
Objective
To estimate trends in contraceptive use, especially long-acting reversible contraceptives (LARC) and condoms, among human immunodeficiency virus (HIV)-seropositive and HIV-seronegative women.
Methods
HIV-seropositive and HIV-seronegative women in a multicenter longitudinal cohort were interviewed semiannually between 1998 and 2010 about sexual behaviors and contraceptive use. Trends in contraceptive use by women aged 18–45 years who were at risk for unintended pregnancy but not trying to conceive were analyzed using generalized estimating equations.
Results
Condoms were the dominant form of contraception for HIV-seropositive women and showed little change across time. Fewer than 15% of these women used no contraception. Between 1998 and 2010, LARC use rose among HIV-seronegative women from 4.8% (6/126) to 13.5% (19/141, p=0.02), but not significantly among seropositive women (0.9% (4/438) to 2.8% (6/213, p = 0.09). Use of highly effective contraceptives, including pills, patches, rings, injectable progestin, implants and intrauterine devices, ranged from 15.2% (53/348) in 1998 to 17.4% (37/213) in 2010 (p = 0.55). HIV-seronegative but not seropositive LARC users were less likely than nonusers to use condoms consistently (HR=0.51, 95% C.I. 0.32–0.81, p = 0.004 for seronegative women; HR = 1.09, 95% C.I. 0.96, 1.23 for seropositive women).
Conclusion
Although most HIV-seropositive women use contraception, they rely primarily on condoms and have not experienced the increase in LARC use seen among seronegative women. Strategies to improve simultaneous use of condoms and LARC are needed to minimize risk of unintended pregnancy as well as HIV transmission and acquisition of sexually transmitted infections.
doi:10.1097/AOG.0b013e318269c8bb
PMCID: PMC3449062  PMID: 22996095
5.  Correlating knowledge of cervical cancer prevention and human papillomavirus with compliance after colposcopy referral 
Objective
To assess the impact of knowledge of cervical cancer biology and prevention as well as noncognitive measures on compliance with colposcopy referral in a high risk population.
Methods
Participants in a U.S. cohort of women with human immunodeficiency virus (HIV) and at risk comparison women completed behavior questionnaires and instruments measuring knowledge of cervical cancer prevention, depressive symptoms, trust in doctors, and perceived stress. Examinations including Pap tests also were conducted. Associations with compliance with resulting indicated colposcopy were assessed in multivariable models.
Results
Of 326 women with indicated colposcopy, 222 (68%) were compliant with colposcopy referral and 104 (32%) noncompliant. In multivariable analysis, better colposcopy compliance was associated with less education (O.R. for compliance 2.24, 95% C.I. 1.12–4.51 vs more than high school), prior abnormal Pap (O.R. per prior abnormal Pap 1.08 95% C.I. 1.01–1.15), study site (O.R. for site with best vs worst compliance 16.1, 95% C.I. 2.91–88.6), and higher stress (O.R. for Perceived Stress Scale-10 score >16 vs lower 3.25, 95% C.I. 1.45–7.26).
Conclusion
Noncognitive factors and how sites manage abnormal Pap testing affect colposcopy compliance. Educational interventions alone are unlikely to improve colposcopy compliance in similar high-risk populations.
doi:10.1097/LGT.0b013e318238e83d
PMCID: PMC3760241  PMID: 22227841
HPV; cervical cancer prevention; Pap test; health education; perceived stress; HIV in women
6.  CHRONIC DEPRESSIVE SYMPTOMS AND FRAMINGHAM CORONARY RISK IN HIV- INFECTED AND UNINFECTED WOMEN 
AIDS Care  2011;24(3):394-403.
Depression is common in people with cardiovascular diseases (CVD) and those with HIV, and is a risk factor for CVD-related mortality. However, little is known about whether HIV influences the relationship between depression and cardiovascular risk. 526 HIV-infected and 132 uninfected women from the Women’s Interagency HIV Study were included in an analysis of women who completed twice-yearly study visits over 9.5 years. CVD risk was calculated at baseline and approximately 9.5 years later using the Framingham Risk Score (FRS). Chronic depressive symptoms were defined as Center for Epidemiologic Studies Depression Scale scores of 16 or greater at ≥75% of study visits. Over the follow-up period, 22.8% of HIV-infected women and 15.9% of HIV-uninfected women had chronic depressive symptoms (p=0.08). Baseline FRS were similar between HIV infected and uninfected women (M=−5.70±SE=0.30 vs. M=−6.90± SE=0.60, p=0.07) as was follow-up FRS (M=0.82±SE=0.30 vs. M=−0.44± SE=0.73, p=0.11). Among HIV-infected and uninfected women, together, follow-up FRS were higher among women with chronic depressive symptoms as compared to those without (M=1.3± SE=0.6 vs. M=−0.3± SE=0.40, p<0.01), after adjusting for baseline FRS and other covariates. HIV status did not modify the relationship between chronic depressive symptoms and FRS. Chronic depressive symptoms accelerated CVD risk scores to a similar extent in both HIV infected and uninfected women. This implies that the diagnosis and treatment of depression may be an important consideration in CV risk reduction in the setting of HIV-infection. The determination of factors that mediate the depression/CVD relationship merits further study.
doi:10.1080/09540121.2011.608791
PMCID: PMC3243818  PMID: 21902560
7.  Contexts of risk and networks of protection: NYC West Indian immigrants’ perceptions of migration and vulnerability to sexually transmitted diseases 
Culture, health & sexuality  2011;13(5):513-528.
To generate insights into how migration shapes sexual risk and protection, we interviewed 36 female and 20 male West Indian (WI) immigrants attending a public sexually transmitted disease (STD) clinic in Brooklyn, NY between 2004 and 2005. Migration theory suggests that shifts in sexual partnership patterns, bi-directional travel, and changes in sexual norms may alter risk. We found evidence of sexual mixing across ethnic groups: a large proportion of participants’ partners were not born in the WIs, despite what is expected among first generation immigrants. Recent travel “home,” another potential source of risk, was uncommon. In open-ended interviews, two themes around sexual and social networks emerged. First, immigrants believed that access to wider, more anonymous sexual networks in NYC and the weakening of social controls that limit multiple partnerships (especially for women) promoted greater risk. Second, immigrants experienced greater opportunities for protection in NYC, both through exposure to safer sex messages and availability of condoms. Reported changes in their own condom use, however, were not attributed to migration. WI immigrants’ risk in NYC may be driven by access to wider sexual networks but failure to alter reliance on “networks of knowledge” for protection.
doi:10.1080/13691058.2011.562304
PMCID: PMC3407273  PMID: 21452091
Caribbean; West Indian; migration; sexual health; sexual networks; HIV/STD
8.  HIV Infection and Women’s Sexual Functioning 
Objective
To compare sexual problems among HIV-positive and HIV-negative women, and describe clinical and psychosocial factors associated with these problems.
Design
Data were collected during a study visit of the Women’s Interagency HIV Study (WIHS). The WIHS studies the natural and treated history of HIV among women in the United States.
Methods
Between 10/01/2006 and 3/30/2007, 1,805 women (1,279 HIV-positive and 526 HIV-negative) completed a study visit that included administration of the Female Sexual Function Index (FSFI). In addition, the visit included completion of standardized, interviewer-administered surveys, physical and gynecological examinations, and blood sample collection.
Results
Women with HIV reported greater sexual problems than did those without HIV. Women also reported lower sexual function if they were classified as menopausal, had symptoms indicative of depression, or if they reported not being in a relationship. CD4+ cell count was associated with FSFI scores, such that those with CD4 ≤199 cells/µL reported lower functioning as compared to those whose cell count was 200 or higher.
Conclusions
Given research documenting relationships between self-reported sexual problems and both clinical diagnoses of sexual dysfunction and women’s quality of life, greater attention to this issue as a potential component of women’s overall HIV care is warranted.
doi:10.1097/QAI.0b013e3181d01b14
PMCID: PMC2900377  PMID: 20179602
HIV; Women; Sexual Behavior; Sexual Problems
9.  Association of Race, Substance Abuse, and Health Insurance Coverage With Use of Highly Active Antiretroviral Therapy Among HIV-Infected Women, 2005 
American journal of public health  2009;100(8):1493-1499.
Objectives
We examined racial/ethnic disparities in highly active antiretroviral therapy (HAART) use and whether differences are moderated by substance use or insurance status, using data from the Women’s Interagency HIV Study (WIHS).
Methods
Logistic regression examined HAART use in a longitudinal cohort of women for whom HAART was clinically indicated in 2005 (N=1354).
Results
Approximately 3 of every 10 eligible women reported not taking HAART. African American and Hispanic women were less likely than were White women to use HAART. After we adjusted for potential confounders, the higher likelihood of not using HAART persisted for African American but not for Hispanic women. Uninsured and privately insured women, regardless of race/ethnicity, were less likely than were Medicaid enrollees to use HAART. Although alcohol use was related to HAART nonuse, illicit drug use was not.
Conclusions
These findings suggest that expanding and improving insurance coverage should increase access to antiretroviral therapy across racial/ethnic groups, but it is not likely to eliminate the disparity in use of HAART between African American and White women with HIV/AIDS.
doi:10.2105/AJPH.2008.158949
PMCID: PMC2901300  PMID: 19910347
10.  Prevalence of Clinical Symptoms Associated with Highly Active Antiretroviral Therapy in the Women’s Interagency HIV Study 
Background
The extended use of antiretroviral drugs among human immunodeficiency virus (HIV)–seropositive individuals underscores the need for a comprehensive evaluation of therapy-associated clinical symptoms.
Methods
Beginning in April 2000, 364 HIV-seronegative and 1256 HIV-seropositive women enrolled in a multicenter cohort study reported clinical symptoms that included abdominal pain, diarrhea, anorexia, nausea and/or vomiting, myalgias, fatigue, fever, body fat redistribution, dizziness, headaches, paresthesias, xerostomia, nephrolithiasis, and rash. We examined the prevalence of symptoms with respect to HIV infection and the use of highly active antiretroviral therapy (HAART), using data-correlation models.
Results
In the 6 months before a study visit, 49% of HIV-seronegative women, 67% of HIV-seropositive women not receiving therapy, and 69% of HIV-seropositive women receiving HAART reported any clinical symptom. The odds ratios (ORs) for reporting any symptom were 1.4 (95% confidence interval [CI], 1.1–1.8) for women who changed HAART regimens and 0.9 (95% CI, 0.7–1.1) for women reporting stable HAART use, compared with those reporting no therapy use. Significant findings (P < .05) for particular symptoms were an increased odds of diarrhea, nausea and/or vomiting, body fat redistribution, myalgias, and paresthesias, when data for women who changed HAART regimens were compared with those for women not receiving therapy. The OR for reporting any symptom was 1.5 (95% CI, 1.2–1.9) for women who switched HAART regimens and 1.6 (95% CI, 1.3–1.9) for women who discontinued HAART, compared with those reporting stable HAART use.
Conclusions
Our findings confirm the high prevalence of clinical symptoms among HIV-seropositive women who changed HAART regimens. The high prevalence of symptoms among HIV-seronegative women and HIV-seropositive women not receiving therapy demonstrates that caution should be used when attributing the occurrence of symptoms entirely to HAART.
doi:10.1086/423181
PMCID: PMC3118991  PMID: 15356788
11.  Knowledge of cervical cancer prevention and human papillomavirus among women with HIV 
Gynecologic oncology  2010;117(1):70-76.
Objective
To assess knowledge of and attitudes towards human papillomavirus (HPV), Pap testing, and the HPV vaccine.
Methods
In a multicenter U.S. cohort study, women with the human immunodeficiency virus (HIV) and at-risk comparison women completed 44-item standardized self-report questionnaires exploring their knowledge of cervical cancer prevention, HPV, and HPV vaccination. Results were correlated with demographic variables, measures of education and attention, and medical factors. Data were clustered using principal component analysis. Significant associations were assessed in multivariable models.
Results
Among 1588 women, HIV seropositive women better understood facts about cervical cancer prevention and HPV than seronegative women, but both had substantial knowledge deficits. Almost all women considered Pap testing important, although 53% of HIV seropositive and 48% of seronegative women considered cervical cancer not preventable (P=0.21). Only 44% of HIV seropositive women knew Paps assess the cervix, versus 42% of HIV seronegative women (P=0.57). Both groups understood that HPV causes genital warts and cervical cancer (67% of HIV seropositive vs. 55% of seronegative women, P=0.002). About half of both groups considered HPV vaccination extremely important for cervical cancer prevention. HIV seronegative women were more likely to report learning of HPV vaccination through advertising than from clinicians (81% vs. 64%, P<0.0001).
Conclusion
High risk women need effective education about cervical cancer prevention, HPV, and HPV vaccination.
doi:10.1016/j.ygyno.2009.12.030
PMCID: PMC3100195  PMID: 20106513
HPV; Cervical cancer prevention; Pap test; Health education; HIV in women
12.  Disclosure of Complementary and Alternative Medicine Use to Health Care Providers among HIV-Infected Women 
AIDS Patient Care and STDs  2009;23(11):965-971.
Abstract
To determine prevalence and predictors of complementary and alternative medicine (CAM) use disclosure to health care providers and whether CAM use disclosure is associated with highly active antiretroviral therapy (HAART) adherence among HIV-infected women, we analyzed longitudinal data collected between October 1994 and March 2002 from HIV-infected CAM-using women enrolled in the Women's Interagency HIV Study. Repeated measures Poisson regression models were constructed to evaluate associations of selected predictors with CAM use disclosure and association between CAM use disclosure and HAART adherence. A total of 1377 HIV-infected women reported CAM use during study follow-up and contributed a total of 4689 CAM-using person visits. The overall prevalence of CAM use disclosure to health care providers was 36% across study visits. Women over 45 years old, with a college education, or with health insurance coverage were more likely to disclose their CAM use to health care providers, whereas women identified as non-Hispanic Black or other ethnicities were less likely to communicate their CAM usage. More health care provider visits, more CAM domains used, and higher health care satisfaction scores had significant relationships with increased levels of CAM use disclosure. Restricting analysis to use of herbal or nonherbal medications only, similar results were obtained. Compared to other CAM domains, mind–body practice had the lowest prevalence of CAM use disclosure. Additionally, CAM use disclosure was significantly associated with higher HAART adherence. From this study, we showed that a high percentage of HIV-infected women did not discuss their CAM use with health care providers. Interventions targeted towards both physicians and patients may enhance communication of CAM use, avoid potential adverse events and drug interactions, and enhance HAART adherence.
doi:10.1089/apc.2009.0134
PMCID: PMC2801553  PMID: 19821723
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.  Disclosure of Complementary and Alternative Medicine Use to Health Care Providers among HIV-Infected Women 
AIDS patient care and STDs  2009;23(11):965-971.
To determine prevalence and predictors of complementary and alternative medicine (CAM) use disclosure to health care providers and whether CAM use disclosure is associated with highly active antiretroviral therapy (HAART) adherence among HIV-infected women, we analyzed longitudinal data collected between October 1994 and March 2002 from HIV-infected CAM-using women enrolled in the Women’s Interagency HIV Study. Repeated measures Poisson regression models were constructed to evaluate associations of selected predictors with CAM use disclosure and association between CAM use disclosure and HAART adherence. A total of 1377 HIV-infected women reported CAM use during study follow-up and contributed a total of 4689 CAM-using person visits. The overall prevalence of CAM use disclosure to health care providers was 36% across study visits. Women over 45 years old, with a college education, or with health insurance coverage were more likely to disclose their CAM use to health care providers, whereas women identified as non-Hispanic Black or other ethnicities were less likely to communicate their CAM usage. More health care provider visits, more CAM domains used, and higher health care satisfaction scores had significant relationships with increased levels of CAM use disclosure. Restricting analysis to use of herbal or nonherbal medications only, similar results were obtained. Compared to other CAM domains, mind–body practice had the lowest prevalence of CAM use disclosure. Additionally, CAM use disclosure was significantly associated with higher HAART adherence. From this study, we showed that a high percentage of HIV-infected women did not discuss their CAM use with health care providers. Interventions targeted towards both physicians and patients may enhance communication of CAM use, avoid potential adverse events and drug interactions, and enhance HAART adherence.
doi:10.1089/apc.2009.0134
PMCID: PMC2801553  PMID: 19821723
16.  Predictors of Partner Notification for C. trachomatis and N. gonorrhoeae: An Examination of Social Cognitive and Psychological Factors 
Efforts to control chlamydial and gonococcal infections include notifying eligible sexual partners of possible infection, primarily by asking the diagnosed patient to notify their partners. This approach, known as patient referral, is widely used but poorly understood. The current study examined psychosocial and cognitive factors associated with patient referral among an urban, minority sample of 168 participants recently diagnosed with Chlamydia trachomatis or Neisseria gonorrhoeae. At a follow-up interview 1-month from diagnosis, participants were more likely to have notified all eligible partners if they had greater intention to notify at baseline (OR = 3.72; 95% CI = 1.34, 10.30) and if they had only one partner at baseline (OR = 4.08; 95% CI = 1.61, 10.31). There were also gender differences as well as differences based on type of partner (i.e., regular, casual, one-time). The implications of these findings for the design of programs to promote patient referral for sexually transmitted infections are discussed.
doi:10.1007/s11524-006-9087-9
PMCID: PMC3261298  PMID: 16817010
Partner notification; Patient referral; STI
17.  Integrating HIV Prevention Activities into the HIV Medical Care Setting: A Report from the NYC HIV Centers Consortium 
Journal of Urban Health   2006;83(1):18-30.
With the maturing of the HIV epidemic and availability of potent antiretroviral therapies in the US, priorities for HIV prevention have shifted from general population approaches to case finding, treatment, risk reduction and relapse prevention activities among those at greatest risk for acquiring or transmitting HIV infection. The challenges of this approach include ensuring access and adherence to HIV care and treatment and appropriate prevention activities to ensure adequate and sustained sexual and drug use risk reduction across diverse populations. Experience with approaches to address these issues, particularly in the context of primary care, has been limited. An agenda for future research and practice includes continued development and evaluation of interventions that can address this next generation of health care issues.
doi:10.1007/s11524-005-9004-7
PMCID: PMC2258324  PMID: 16736352
18.  The Perinatal Guidelines Evaluation Project HIV and Pregnancy Study: overview and cohort description. 
Public Health Reports  2002;117(2):137-147.
OBJECTIVE: The HIV and Pregnancy Study of the Perinatal Guidelines Evaluation Project is a prospective, longitudinal, multisite study established to: (a) assess the implementation of Public Health Service guidelines regarding the prevention of perinatal HIV transmission and (b) evaluate the psychosocial consequences of HIV infection among pregnant women. A distinctive aspect of the study is the use of an HIV-negative comparison group. This article describes the methodology of the study and baseline characteristics of the study sample. Methods and Results. HIV-infected (n = 336) and uninfected (n = 298) pregnant women were enrolled from four geographic areas: Connecticut, North Carolina, Brooklyn, NY, and Miami, FL. The study included three structured face-to-face interviews from late pregnancy to six months postpartum for HIV-infected and uninfected women. Additional self-reports of medication adherence were collected for the HIV-infected participants, and the medical records of infected mothers and their infants were reviewed. Electronic monitoring of medication adherence was conducted for a subset of the infected women. The groups were successfully matched on self-reported characteristics, including HIV-risk behaviors. More than half of the uninfected women reported a high-risk sexual partner. Baseline comparisons indicated that both the HIV-infected and uninfected women had high levels of depressive symptoms, stress, and recent negative life events. CONCLUSIONS: This study provides a unique description of the psychosocial and behavioral characteristics of a population of low-income women. The results of this study suggest that HIV infection is one of many stressors faced by the women in this study.
PMCID: PMC1497420  PMID: 12356998
19.  Measuring Retention in HIV Care: The Elusive Gold Standard 
Background
Measuring retention in HIV primary care is complex as care includes multiple visits scheduled at varying intervals over time. We evaluated six commonly used retention measures in predicting viral load (VL) suppression and the correlation among measures.
Methods
Clinic-wide patient-level data from six academic HIV clinics were used for 12-months preceding implementation of the CDC/HRSA Retention in Care intervention. Six retention measures were calculated for each patient based upon scheduled primary HIV provider visits: count and dichotomous missed visits, visit adherence, 6-month gap, 4-month visit constancy, and the HRSA HAB retention measure. Spearman correlation coefficients and separate unadjusted logistic regression models compared retention measures to one another and with 12-month VL suppression, respectively. The discriminatory capacity of each measure was assessed with the c-statistic.
Results
Among 10,053 patients, 8,235 (82%) had 12-month VL measures, with 6,304 (77%) achieving suppression (VL<400 c/mL). All six retention measures were significantly associated (P<0.0001) with VL suppression (OR;95%CI, c-statistic): missed visit count (0.73;0.71–0.75,0.67), missed visit dichotomous (3.2;2.8–3.6,0.62), visit adherence (3.9;3.5–4.3,0.69), gap (3.0;2.6–3.3,0.61), visit constancy (2.8;2.5–3.0,0.63), HRSA HAB (3.8;3.3–4.4,0.59). Measures incorporating “no show” visits were highly correlated (Spearman coefficient=0.83–0.85), as were measures based solely upon kept visits (Spearman coefficient=0.72–0.77). Correlation coefficients were lower across these two groups of measures (Range=0.16–0.57).
Conclusions
Six retention measures displayed a wide range of correlation with one another, yet each measure had significant association and modest discrimination for VL suppression. These data suggest there is no clear gold standard, and that selection of a retention measure may be tailored to context.
doi:10.1097/QAI.0b013e318273762f
PMCID: PMC3508092  PMID: 23011397
Retention in care; Adherence; Engagement in care; Viral load
20.  Medicinal and recreational marijuana use among HIV-infected women in the Women’s Interagency HIV Cohort (WIHS), 1994–2010 
Background
Despite the major benefits of effective antiretroviral therapy (ART) on HIV-related survival, there is an ongoing need to help alleviate medication side effects related to ART use. Initial studies suggest marijuana use may reduce HIV-related symptoms, but medical marijuana use among HIV-infected individuals has not been well described.
Methods
We evaluated trends in marijuana use and reported motivations for use among 2,776 HIV-infected women in the Women’s Interagency HIV Study (WIHS) between October 1994 and March 2010. Predictors of any and daily marijuana use were explored in multivariate logistic regression models clustered by person using GEE. In 2009 participants were asked if their marijuana use was medical, “meaning prescribed by a doctor”, or recreational, or both.
Results
Over the sixteen years of this study the prevalence of current marijuana use decreased significantly from 21% to 14%. In contrast, daily marijuana use almost doubled from 3.3% to 6.1% of all women, and from 18% to 51% of current marijuana users. Relaxation, appetite improvement, reduction of HIV-related symptoms, and social use were reported as common reasons for marijuana use. In 2009, most marijuana users reported either purely medicinal use (26%) or both medicinal and recreational usage (29%). Daily marijuana use was associated with higher CD4 cell count, quality of life, and older age. Demographic characteristics and risk behaviors were associated with current marijuana use overall, but were not predictors of daily use.
Conclusion
This study suggests that both recreational and medicinal marijuana use are relatively common among HIV-infected women in this U.S.
doi:10.1097/QAI.0b013e318273ab3a
PMCID: PMC3508315  PMID: 23011399
marijuana; cannabis; HIV; medicinal
21.  Psychosocial Characteristics and Sexual Behaviors of People in Care for HIV Infection: An Examination of Men Who Have Sex with Men, Heterosexual Men and Women 
AIDS and behavior  2009;13(6):1129-1142.
Few studies have examined the psychosocial factors associated with sexual transmission behaviors among HIV-positive men who have sex with men (MSM), heterosexual men (MSW) and women. We enrolled 1,050 sexually active HIV-positive patients at seven HIV clinics in six US cities as part of a clinic-based behavioral intervention. We describe the sexual transmission behaviors and examine demographic, clinical, psychosocial, and clinic prevention variables associated with unprotected anal or vaginal intercourse (UAVI). Twenty-three percent of MSM, 12.3% of MSW and 27.8% of women engaged in UAVI with partners perceived to be HIV-negative or of unknown serostatus. Among MSM and MSW, having multiple partners and lower self-efficacy were associated with increased odds of UAVI. Self-rating one’s health status as excellent/very good was a risk factor for UAVI among MSM. Among women, binge drinking and stressful life events were associated with UAVI. These findings identify variables that warrant attention in targeted interventions.
doi:10.1007/s10461-009-9613-3
PMCID: PMC3782535  PMID: 19763810
HIV; HIV prevention; Sexual behavior; STDs; STD prevention
22.  Sexual Serosorting among Women with or at Risk of HIV Infection 
AIDS and behavior  2011;15(1):9-15.
Serosorting, the practice of selectively engaging in unprotected sex with partners of the same HIV serostatus, has been proposed as a strategy for reducing HIV transmission risk among men who have sex with men (MSM). However, there is a paucity of scientific evidence regarding whether women engage in serosorting. We analyzed longitudinal data on women’s sexual behavior with male partners collected in the Women’s Interagency HIV Study from 2001 to 2005. Serosorting was defined as an increasing trend of unprotected anal or vaginal sex (UAVI) within seroconcordant partnerships over time, more frequent UAVI within seroconcordant partnerships compared to non-concordant partnerships, or having UAVI only with seroconcordant partners. Repeated measures Poisson regression models were used to examine the associations between serostatus partnerships and UAVI among HIV-infected and HIV-uninfected women. The study sample consisted of 1,602 HIV-infected and 664 HIV-uninfected women. Over the follow-up period, the frequency of seroconcordant partnerships increased for HIV-uninfected women but the prevalence of UAVI within seroconcordant partnerships remained stable. UAVI was reported more frequently within HIV seroconcordant partnerships than among serodiscordant or unknown serostatus partnerships, regardless of the participant’s HIV status or types of partners. Among women with both HIV-infected and HIV-uninfected partners, 41% (63 HIV-infected and 9 HIV-uninfected) were having UAVI only with seroconcordant partners. Our analyses suggest that serosorting is occurring among both HIV-infected and HIV-uninfected women in this cohort.
doi:10.1007/s10461-010-9710-3
PMCID: PMC2987377  PMID: 20490909
HIV; Unprotected sex; Serosorting; Risk reduction; Condom use
23.  Changes in Knowledge of Cervical Cancer Prevention and Human Papillomavirus Among Women With Human Immunodeficiency Virus: 2006-2008 
Obstetrics and gynecology  2010;116(4):941-947.
Objective
To estimate changes in high risk women’s knowledge of cervical cancer prevention, human papillomavirus (HPV), and HPV vaccination since introduction and marketing of HPV vaccines.
Methods
At study visits in 2006 and 2008, women with the human immunodeficiency virus (HIV) and at-risk comparison women in a multicenter U.S. cohort study completed 44-item self-report questionnaires exploring their knowledge of cervical cancer prevention, HPV, and HPV vaccination. Results from 2006 were compared to those obtained in 2008. Knowledge scores were correlated with demographic variables, measures of education and attention, and medical factors. Significant associations were assessed in multivariable models.
Results
HIV-seropositive women had higher knowledge scores than seronegative women at baseline (13.2 +/− 5.7 vs 11.8 +/− 6.0, P = 0.0002) and follow-up (14.1 +/− 5.3 vs 13.2 +/− 5.5, P = 0.01), but the change in scores was similar (0.9 +/− 5.3 vs 1.5 +/− 5.5, P = 0.13). Knowledge that cervical cancer is caused by a virus rose significantly (P = 0.005), but only to 24%. Belief that cervical cancer is preventable only rose from 52% to 55% (P = 0.04), but more than 90% of women in both periods believed regular Pap testing was important. In ANCOVA models, higher baseline score, younger age, higher education level, higher income, and former- as opposed to never-drug users, but not HIV status, were associated with improved knowledge.
Conclusion
High-risk women’s understanding of cervical cancer and HPV has improved, but gaps remain. Improvement has been weakest for less-educated and lower-income women.
doi:10.1097/AOG.0b013e3181f2dbae
PMCID: PMC3248790  PMID: 20859159
24.  Multi-Dimensional Risk Factor Patterns Associated with Non-use of HAART among HIV-Infected Women 
Objectives
Relationships between non-use of highly active anti-retroviral therapy (HAART), race/ethnicity, violence, drug use and other risk factors are investigated using qualitative profiles of five risk factors (unprotected sex, multiple male partners, heavy drinking, crack, cocaine or heroin use, and exposure to physical violence) and association of the profiles and race/ethnicity with non-use of HAART over time.
Methods
A Hidden Markov Model (HMM) was used to summarize risk factor profiles and changes in profiles over time in a longitudinal sample of HIV-infected women enrolled in the Women's Interagency HIV Study (WIHS) with follow-up from 2002 to 2005 (N=802).
Results
Four risk factor profiles corresponding to four distinct latent states were identified from the five risk factors. Trajectory analysis indicated that states characterized by high probabilities of all risk factors or by low probabilities of all risk factors were both relatively stable over time. Being in the highest risk state did not significantly elevate the odds of HAART non-use (OR: 1.05; 95% CI: 0.6-1.8). However, being in a latent state characterized by elevated probabilities of heavy drinking and exposure to physical violence, along with slight elevations in three other risk factors, significantly increased odds of HAART non-use (OR: 1.4; 95% CI: 1.1-1.9).
Conclusions
The research suggests that HAART use might be improved by interventions aimed at women who are heavy drinkers with recent exposure to physical violence and evidence of other risk factors. More research about the relationship between clustering and patterns of risk factors and use of HAART is needed.
doi:10.1016/j.whi.2010.03.005
PMCID: PMC2930097  PMID: 20579905
25.  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

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