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1.  Do Sexual Networks of Men Who Have Sex with Men in New York City Differ by Race/Ethnicity? 
AIDS Patient Care and STDs  2016;30(1):39-47.
The United States HIV epidemic disproportionately affects black and Hispanic men who have sex with men (MSM). This disparity might be partially explained by differences in social and sexual network structure and composition. A total of 1267 MSM in New York City completed an ACASI survey and egocentric social and sexual network inventory about their sex partners in the past 3 months, and underwent HIV testing. Social and sexual network structure and composition were compared by race/ethnicity of the egos: black, non-Hispanic (N = 365 egos), white, non-Hispanic (N = 466), and Hispanic (N = 436). 21.1% were HIV-positive by HIV testing; 17.2% reported serodiscordant and serostatus unknown unprotected anal/vaginal intercourse (SDUI) in the last 3 months. Black MSM were more likely than white and Hispanic MSM to report exclusively having partners of same race/ethnicity. Black and Hispanic MSM had more HIV-positive and unknown status partners than white MSM. White men were more likely to report overlap of social and sex partners than black and Hispanic men. No significant differences by race/ethnicity were found for network size, density, having concurrent partners, or having partners with ≥10 years age difference. Specific network composition characteristics may explain racial/ethnic disparities in HIV infection rates among MSM, including HIV status of sex partners in networks and lack of social support within sexual networks. Network structural characteristics such as size and density do not appear to have such an impact. These data add to our understanding of the complexity of social factors affecting black MSM and Hispanic MSM in the U.S.
PMCID: PMC4717505  PMID: 26745143
2.  Increased fracture incidence in middle-aged HIV-infected and uninfected women: updated results from the Women’s Interagency HIV Study 
We previously reported that fracture incidence rates did not differ by HIV status among predominantly premenopausal Women's Interagency HIV Study (WIHS) participants. We now conduct a follow-up study with 5 additional observation years, to further characterize fracture risk associated with HIV infection in women as they age.
We measured time to first new fracture at any site in 2375 (1713 HIV-infected, 662 HIV-uninfected) WIHS participants, with median 10 years follow-up. Fractures were self-reported semiannually. Proportional Hazards models assessed predictors of incident fracture.
At index visit, HIV-infected women were older (median age 40 yrs (IQR 34–46) vs. 35 (27–43), p<0.0001) and more likely to be postmenopausal, HCV-infected, and weigh less than HIV-uninfected women. Among HIV-infected women, mean CD4+ count was 480 cells/µL and 63% were taking HAART. Unadjusted incidence rates of any fracture were higher in HIV-infected than uninfected women (2.19/100 person-years (py) vs 1.54/100py, p=0.002). In multivariate models, HIV status, older age, white (vs. black) race, prior fracture, history of cocaine use, and history of injection drug use were significant predictors of incident fracture. Among HIV-infected women, age, white race, prior fracture, smoking, and prior AIDS were predictors of new fracture.
Middle-aged HIV-infected women had a higher adjusted fracture rate than uninfected women. Cocaine use and injection drug use were also associated with a greater risk of incident fracture. Further research is needed to understand whether the risk of fracture associated with cocaine use relates to increased rate of falls, or direct effects on bone metabolism.
PMCID: PMC4557627  PMID: 26322667
HIV; women; bone; fracture; fragility fracture
3.  Sexual behavior and risk practices of HIV positive and HIV negative Rwandan women 
AIDS and behavior  2015;19(7):1366-1378.
It is not well understood how infection with HIV and prior experience of sexual violence affects sexual behavior in African women. We describe factors influencing current sexual practices of Rwandan women living with or without HIV/AIDS. By design, 75% of participants were HIV positive and ~50% reported having experienced genocidal rape. Univariate and multivariate logistic regression models were fit to describe demographic and clinical characteristics that influenced sexual behavior in the previous 6 months, condom use, history of transactional sex, and prior infection with a non-HIV sexually transmitted disease. Respondents’ age, where they lived, whether or not they lived with a husband or partner, experience of sexual trauma, CD4 count, CES-D and PTSD scores were strongly associated with risky sexual behavior and infection with non-HIV STI. HIV positive women with a history of sexual violence in the contexts of war and conflict may be susceptible to some high-risk sexual behaviors.
PMCID: PMC4461563  PMID: 25488169
HIV/AIDS; Sexual behavior; Sexual Trauma; Genocide; Rwanda
4.  Implementation and effectiveness of integrated trauma and addiction treatment for incarcerated men 
A controlled trial of Seeking Safety (SS) and Male-Trauma Recovery Empowerment Model (M-TREM) examined implementation and effectiveness of integrated group therapy for comorbid post-traumatic stress disorder (PTSD) and substance use disorder (SUD) on PTSD and mental health symptoms plus self-esteem and efficacy for incarcerated men. The study sample (n = 230) was male inmates 18 years or older who were primarily non-white, high school graduates or equivalents, had childhood trauma histories, committed violent crimes, had serious mental illnesses, and resided in a maximum security prison. Incarcerated men, who screened positive for PTSD and SUD, were assigned randomly (n = 142) or by preference (n = 88) to receive SS or M-TREM, with a waitlist group of (n = 93). Manualized interventions were group-administered for 14 weeks. Primary outcomes were PTSD and other mental health symptoms. Secondary outcomes were self-esteem, coping, and self-efficacy. SUD outcomes cannot be measured in a correctional setting. Implementation feasibility was exhibited by the ability to recruit, screen, assign, and retain participants. Effectiveness findings depended on sample, design, and method for analysis. Using a waitlist control group and no follow-up period, we found no aggregate effect of treatment on PTSD symptoms, although, when disaggregated, M-TREM was found to improve PTSD severity and SS improved general mental health symptoms and psychological functioning. Using intent-to-treat and completer analyses, no significant differences were found in the relative performance between SS and M-TREM on primary or secondary outcomes. When longitudinal data were maximized and modeled in ways that reflect the hierarchical nature of the data, we found that SS and M-TREM performed better than no treatment on PTSD severity and secondary outcomes, and that treatment benefits endured. Findings cautiously support implementing either Seeking Safety or M-TREM to treat incarcerated men with co-morbid PTSD and addiction problems.
PMCID: PMC4620997  PMID: 25617774
PTSD; Seeking Safety; Trauma Recovery and Empowerment Model (MTREM); Incarcerated men; Integrated treatment
5.  Sexual Orientation- and Race-Based Discrimination and Sexual HIV Risk Behavior Among Urban MSM 
AIDS and behavior  2015;19(2):257-269.
Understanding what social factors are associated with risk of HIV acquisition and transmission among gay, bisexual and other men who have sex with men (MSM) is a critical public health goal. Experiencing discrimination may increase risk of HIV infection among MSM. This analysis assessed relations between experiences of sexual orientation- and race-based discrimination and sexual HIV risk behavior among MSM in New York City. 1,369 MSM completed a self-administered computerized assessment of past 3-month sexual behavior, experience of social discrimination and other covariates. Regression models assessed relations between recent experience of discrimination and sexual HIV risk behavior. Mean age was 32 years; 32 % were white; 32 % Latino/Hispanic; 25 % African American/Black. Of MSM who self-reported HIV-positive or unknown status (377), 7 % (N = 27) reported having unprotected insertive anal intercourse with an HIV-negative or unknown status partner (“HIV transmission risk”). Of MSM who self-reported HIV-negative status (992), 11 % (110) reported unprotected receptive anal intercourse with an HIV-positive or unknown status partner (“HIV acquisition risk”). HIV acquisition risk was positively associated with sexual orientation-based discrimination in home or social neighborhoods, but not race-based discrimination. We observed that sexual orientation-based discrimination was associated with sexual HIV risk behavior among urban-dwelling MSM. Addressing environmental sources of this form of discrimination, as well as the psychological distress that may result, should be prioritized in HIV prevention efforts.
PMCID: PMC4702509  PMID: 25381561
HIV prevention; Social discrimination; Sexual behavior; MSM
6.  Relationship between Body Mass Index and Mortality in HIV-Infected HAART Users in the Women's Interagency HIV Study 
PLoS ONE  2015;10(12):e0143740.
Early HIV studies suggested protective associations of overweight against mortality, yet data are lacking for the era of potent highly active antiretroviral therapy (HAART). We evaluated associations of pre-HAART initiation body mass index (BMI) with mortality among HAART-using women.
Prospective study of time to death after HAART initiation among continuous HAART users in the Women’s Interagency HIV Study. Unadjusted Kaplan–Meier and adjusted proportional hazards survival models assessed time to AIDS and non-AIDS death by last measured pre-HAART BMI.
Of 1428 continuous HAART users 39 (2.7%) were underweight, 521 (36.5%) normal weight, 441 (30.9%) overweight, and 427 (29.9%) obese at time of HAART initiation. A total of 322 deaths occurred during median follow-up of 10.4 years (IQR 5.9–14.6). Censoring at non-AIDS death, the highest rate of AIDS death was observed among underweight women (p = 0.0003 for all 4 categories). In multivariate models, women underweight prior to HAART died from AIDS more than twice as rapidly vs. normal weight women (aHR 2.04, 95% CI 1.03, 4.04); but being overweight or obese (vs. normal weight) was not independently associated with AIDS death. Cumulative incidence of non-AIDS death was similar across all pre-HAART BMI categories.
Among continuous HAART-using women, being overweight prior to initiation was not associated with lower risk of AIDS or non-AIDS death. Being underweight prior to HAART was associated with over double the rate of AIDS death in adjusted analyses. Although overweight and obesity may be associated with many adverse health conditions, neither was predictive of mortality among the HAART-using women.
PMCID: PMC4689347  PMID: 26699870
7.  A randomized trial of a behavioral intervention for Black men who have sex with men: The DiSH Study 
AIDS (London, England)  2012;26(4):483-488.
To test a new behavioral intervention for Black men who have sex with men in reducing sexual risk and increasing social support and intentions to use condoms.
A single site, unblinded randomized trial in New York City with 3-month follow-up.
Participants (n = 283) reporting at least 2 sexual partners and unprotected anal intercourse with a man in the past 3 months were enrolled and randomized to a social-cognitive theory based intervention or control comparison. Men in the intervention group participated in five 2-hour group sessions focused on creating a group environment with sexual risk-reduction information and exercises woven into joint meal preparation and sharing activities, while exploring self-efficacy perceptions and outcome expectancies. Intervention (n = 142) and control (n = 141) groups received standard HIV counseling and testing at baseline.
No significant differences were found between study arms at 3 months in number of male partners, number of unprotected anal intercourse partners, proportion reporting unprotected sex, number of acts protected by condoms, self-efficacy, condom attitudes, condom intentions, social isolation and psychological distress. In both arms combined, declines from baseline to 3-months were observed in sexual risk behaviors, social isolation and psychological distress while self-efficacy, condom attitudes and condom intentions improved.
As the HIV epidemic continues to have a dramatic impact on Black MSM in the US, the urgency to design innovative interventions continues.
PMCID: PMC4633031  PMID: 22156967
behavioral intervention; Black/African-American; gay men; HIV
8.  Association of Markers of Hemostasis with Death in HIV-infected Women 
In HIV-negatives, markers of hemostasis including D-dimer, Factor VIII, plasminogen activator inhibitor-1 antigen (PAI-1) and total protein S are associated with all-cause and cardiovascular disease mortality. In HIV-positives, studies of D-dimer and Factor VIII with death were limited to short follow-up; associations of PAI-1 and total protein S with death have not been examined.
In 674 HIV-infected women from the Women’s Interagency HIV Study (WIHS), markers from the first visit after enrollment were exposures of interest in multivariate analyses of death (AIDS and non-AIDS) in separate models at 5 and 16 years.
There were 87 AIDS and 44 non-AIDS deaths at 5 years, and 159 AIDS and 113 non-AIDS deaths at 16 years. An inverse association of total protein S quartiles with non-AIDS deaths was observed at 5 (p-trend=0.002) and 16 years (p-trend=0.02); there was no association with AIDS deaths. The 3rd quartile of PAI-1 was associated with AIDS deaths at 5 (hazard ratio (HR)=4.0, 95% confidence interval (CI)=1.9–8.4) and 16 years (HR=3.4, 95% CI=1.9–5.9); and with non-AIDS deaths at 5 years (HR=4.8, 95%CI=1.6,13.9). D-dimer and Factor VIII were not associated with AIDS or non-AIDS death at 5 or 16 years.
Lower total Protein S was a consistent marker of non-AIDS death. We found no association between D-dimer with AIDS or non-AIDS death, in contrast to previous studies showing increased short term (<5 years) mortality, which may represent sex differences or population heterogeneity. Given longer survival on HAART, further studies of these markers are needed to determine their prognostic value.
PMCID: PMC4197808  PMID: 25314249
9.  Liberal versus restrictive blood transfusion strategy: 3-year survival and cause of death results from the FOCUS randomised controlled trial 
Lancet (London, England)  2014;385(9974):1183-1189.
Blood transfusion might affect long-term mortality by changing immune function and thus potentially increasing the risk of subsequent infections and cancer recurrence. Compared with a restrictive transfusion strategy, a more liberal strategy could reduce cardiac complications by lowering myocardial damage, thereby reducing future deaths from cardiovascular disease. We aimed to establish the effect of a liberal transfusion strategy on long-term survival compared with a restrictive transfusion strategy.
In the randomised controlled FOCUS trial, adult patients aged 50 years and older, with a history of or risk factors for cardiovascular disease, and with postoperative haemoglobin concentrations lower than 100 g/L within 3 days of surgery to repair a hip fracture, were eligible for enrolment. Patients were recruited from 47 participating hospitals in the USA and Canada, and eligible participants were randomly allocated in a 1:1 ratio by a central telephone system to either liberal transfusion in which they received blood transfusion to maintain haemoglobin level at 100 g/L or higher, or restrictive transfusion in which they received blood transfusion when haemoglobin level was lower than 80 g/L or if they had symptoms of anaemia. In this study, we analysed the long-term mortality of patients assigned to the two transfusion strategies, which was a secondary outcome of the FOCUS trial. Long-term mortality was established by linking the study participants to national death registries in the USA and Canada. Treatment assignment was not masked, but investigators who ascertained mortality and cause of death were masked to group assignment. Analyses were by intention to treat. The FOCUS trial is registered with, number NCT00071032.
Between July 19, 2004, and Feb 28, 2009, 2016 patients were enrolled and randomly assigned to the two treatment groups: 1007 to the liberal transfusion strategy and 1009 to the restrictive transfusion strategy. The median duration of follow-up was 3·1 years (IQR 2·4–4·1 years), during which 841 (42%) patients died. Long-term mortality did not differ significantly between the liberal transfusion strategy (432 deaths) and the restrictive transfusion strategy (409 deaths) (hazard ratio 1·09 [95% CI 0·95–1·25]; p=0·21).
Liberal blood transfusion did not affect mortality compared with a restrictive transfusion strategy in a high-risk group of elderly patients with underlying cardiovascular disease or risk factors. The underlying causes of death did not differ between the trial groups. These findings do not support hypotheses that blood transfusion leads to long-term immunosuppression that is severe enough to affect long-term mortality rate by more than 20–25% or cause of death.
National Heart, Lung, and Blood Institute.
PMCID: PMC4498804  PMID: 25499165
10.  Association of Abnormal Liver Function Parameters with HIV Serostatus and CD4 Count in Antiretroviral-Naive Rwandan Women 
We determined the associations of HIV infection/CD4 count with markers of hepatocellular damage [elevated aspartate aminotransferase (AST) and alanine aminotransferase (ALT)] and liver synthetic function (decreased albumin) in HIV-infected (HIV+) antiretroviral therapy (ART)-naive and uninfected (HIV−) Rwandan women. In 2005, 710 HIV+ ART-naive and 226 HIV− women enrolled in the Rwanda Women's Interassociation Study and Assessment. Liver enzymes were measured with abnormality defined as either AST or ALT ≥1.25 times the upper limit of normal. Low serum albumin level was defined as <3.5 g/dl. Multivariable logistic regression analysis identified independent predictors of elevated AST/ALT and low serum albumin. HIV− women had the lowest prevalence (6.6%) of abnormal AST/ALT, with the highest prevalence (16.4%) in HIV+ women with CD4 <200 cells/μl (p=0.01). The odds of having serum albumin <3.5 g/dl was 5.7-fold higher in HIV+ than HIV− women (OR=5.68, 95% CI: 3.32–9.71). The risk of low albumin decreased from low to high CD4 count, with OR=2.62, 95% CI: 1.66, 4.14 and OR=1.57, 95% CI: 1.01, 2.43 in HIV+ women with a CD4 count <200 and 200–350 cells/μl, respectively vs. HIV+ with CD4 >350 (p<0.001 and p<0.05 for all comparisons). Our findings suggest that HIV-associated liver damage may occur in ART-naive patients. Although liver abnormality prevalences in this cohort of HIV-infected Rwandan women are less than reported in developed countries, caution is needed for risk assessment measures to monitor and screen HIV-infected patients pre- and post-ART initiation in African clinical settings to curtail potential risks associated with HIV infection.
PMCID: PMC4505765  PMID: 25924728
11.  Consultations Between Patients With Breast Cancer and Surgeons: A Pathway From Patient-Centered Communication to Reduced Hopelessness  
Journal of Clinical Oncology  2012;31(3):351-358.
Patient-centered communication (PCC) affects psychosocial health outcomes of patients. However, these effects are rarely direct, and our understanding of such effects are largely based on self-report (v observational) data. More information is needed on the pathways by which concrete PCC behaviors affect specific psychosocial outcomes in cancer care. We hypothesized that PCC behaviors increase the satisfaction of patients with surgeons, which, in turn, reduces the postconsultation hopelessness of patients.
Patients and Methods
In Portland, OR, we videotaped consultations between 147 women newly diagnosed with breast cancer and nine surgeons and administered surveys to participants immediately preconsultation and postconsultation. Consultations were coded for PCC behaviors. Multivariate regression models analyzed the association between PCC and the satisfaction of patients and between satisfaction and hopelessness.
Levels of hopelessness of patients significantly decreased from preconsultation to postconsultation (P < .001). Two PCC behaviors (ie, patient asserting treatment preference [odds ratio {OR}, 1.50/log unit; 95% CI, 1.01 to 2.23/log unit; P = .042] and surgeon providing good/hopeful news [OR, 1.62/log unit; 95% CI, 1.01 to 2.60/log unit; P = .047]) were independently significantly associated with the satisfaction of patients with surgeons, which, in turn, independently predicted reduced levels of postconsultation hopelessness (linear change, −0.78; 95% CI, 1.44 to −0.12; P = .02).
Although additional research is needed with larger and more-diverse data sets, these findings suggest the possibility that concrete and trainable PCC behaviors can lower the hopelessness of patients with breast cancer indirectly through their effects on patient satisfaction with care.
PMCID: PMC3732013  PMID: 23233706
12.  Longitudinal Anthropometric Patterns Among HIV-infected and –uninfected Women 
Previous studies suggest that indicators of central adiposity such as waist-to-hip ratio (WHR) and waist circumference may be altered by HIV infection, antiretroviral (ARV) treatment or both.
Waist and hip circumference and body mass index (BMI) were measured among participants of the Women’s Interagency HIV Study (WIHS) semiannually from 1999 to 2004. Generalized linear models evaluated longitudinal patterns of these measures and associations with demographic and clinical characteristics.
WHR was significantly larger while BMI, waist and hip circumference were significantly smaller at almost all eleven semiannual visits among 942 HIV-infected compared to 266 HIV-uninfected women. Among HIV-uninfected women, mean waist and hip circumference and BMI increased over the 5 year study period (waist: +4.1 cm or 4.4%, hip: +3.76 cm or 3.5% and BMI +2.43 kg/m2 or 8.2%), while WHR remained stable. Among the HIV-infected women, waist and hip circumference, BMI and WHR did not significantly change.
Independent predictors of smaller BMI among HIV-infected women included White race, HCV seropositivity, current smoking, higher viral load and lower CD4. Independent predictors of larger WHR among HIV-infected women included age, White and Other non-African-American race, higher CD4 and PI use. Use of a HAART regimen was not an independent predictor of either BMI or WHR..
HIV-infected women had higher WHR compared to HIV-uninfected women, despite lower BMI, waist and hip measurements. BMI, waist and hip circumference increased over 5 years among the HIV-uninfected women, but remained stable in the HIV-infected women. Among HIV-infected women, PI use was associated with larger WHR, although HAART use itself was not appreciably associated with either BMI or WHR.
PMCID: PMC4406344  PMID: 18197125
anthropometrics; HIV; women; waist-to-hip ratio
13.  Insulin Resistance Change and Antiretroviral Therapy Exposure in HIV-Infected and Uninfected Rwandan Women: A Longitudinal Analysis 
PLoS ONE  2015;10(4):e0123936.
We longitudinally assessed predictors of insulin resistance (IR) change among HIV-uninfected and HIV-infected (ART-initiators and ART-non-initiators) Rwandan women.
HIV-infected (HIV+) and uninfected (HIV-) women provided demographic and clinical measures: age, body mass index (BMI) in Kg/(height in meters)2, Fat-Mass (FMI) and Fat-Free-Mass (FFMI) index, fasting serum glucose and insulin. Homeostasis Model Assessment (HOMA) was calculated to estimate IR change over time in log10 transformed HOMA measured at study enrollment or prior to ART initiation in 3 groups: HIV- (n = 194), HIV+ ART-non-initiators (n=95) and HIV+ ART-initiators (n=371). ANCOVA linear regression models of change in log10-HOMA were fit with all models included the first log10 HOMA as a predictor.
Mean±SD log10-HOMA was -0.18±0.39 at the 1st and -0.21±0.41 at the 2nd measure, with mean change of 0.03±0.44. In the final model (all women) BMI at 1st HOMA measure (0.014; 95% CI=0.006-0.021 per kg/m2; p<0.001) and change in BMI from 1st to 2nd measure (0.024; 95% CI=0.013-0.035 per kg/m2; p<0.001) predicted HOMA change. When restricted to subjects with FMI measures, FMI at 1st HOMA measure (0.020; 95% CI=0.010-0.030 per kg/m2; p<0.001) and change in FMI from 1st to 2nd measure (0.032; 95% CI=0.020-0.043 per kg/m2; p<0.0001) predicted change in HOMA. While ART use did not predict change in log10-HOMA, untreated HIV+ women had a significant decline in IR over time. Use or duration of AZT, d4T and EFV was not associated with HOMA change in HIV+ women.
Baseline BMI and change in BMI, and in particular fat mass and change in fat mass predicted insulin resistance change over ~3 years in HIV-infected and uninfected Rwandan women. Exposure to specific ART (d4T, AZT, EFV) did not predict insulin resistance change in ART-treated HIV-infected Rwandan women.
PMCID: PMC4400132  PMID: 25880634
14.  Prevalence of shingles and its association with PTSD among HIV-infected women in Rwanda 
BMJ Open  2015;5(3):e005506.
To examine the prevalence of reported shingles in the last 6 months and its association with post-traumatic stress disorder (PTSD), depression and severity of HIV disease in Rwandan women with HIV.
This cross-sectional study was conducted as part of the Rwanda Women's Interassociation Study and Assessment (RWISA), an observational cohort study designed to assess the impact of HIV and residual factors from experiencing rape in the 1994 genocide in Rwandan women. Participants were recruited through grassroots women's associations of people living with HIV infection and clinical care sites for HIV infection. Most participants (58.5%, n=405/692) had PTSD.
This cross-sectional analysis was conducted in 710 HIV-infected women enrolled in RWISA. Inclusion criteria were: age >15 years, informed consent, HIV test, ability to complete the interview in the local language, travel to and from the research site and participate in a baseline outpatient visit, and being naive to antiretroviral therapy at enrolment.
Primary and secondary outcome measures
The outcome of interest was self-reported shingles in the past 6 months. The exposure was PTSD defined using the cross-culturally validated Harvard Trauma Questionnaire.
Overall prevalence of reported shingles in the past 6 months was 12.5% (n=89/710). There was an inverse relationship between shingles prevalence and immunological status: 7.6%, 12.3% and 16.7% of women with CD4 >350, 200–350 and <200 cells/µL, respectively, reported singles (p=0.01). In multivariate analysis, PTSD (aOR 1.7; 95% CI 1.02 to 2.89) and low CD4 (aOR 2.4; 95% CI 1.23 to 4.81) were independently associated with reported shingles in the past 6 months.
Our study found a significant independent relationship between PTSD and reported shingles, suggesting that PTSD may be associated with immune compromise that can result in herpes zoster reactivation. Further study is needed. It also confirmed previous findings of a strong relationship between shingles and greater immunosuppression in women with HIV infection.
PMCID: PMC4360726  PMID: 25748413
HIV/AIDS; Shingles; PTSD; Depression
15.  Prevalence and risk factors for High-Risk Human Papillomavirus (hrHPV) infection among HIV-infected and Uninfected Rwandan women: implications for hrHPV-based screening in Rwanda 
New World Health Organization guidelines recommend high-risk human papillomavirus (hrHPV) screen-and-treat strategies for cervical cancer prevention. We describe risk of, and risk factors for, testing hrHPV positive in a pilot study of hrHPV screen-and-treat conducted in Rwanda.
A total of 2,964 women, 1,289 HIV-infected (HIV [+]) and 1,675 HIV-uninfected (HIV [-]), aged 30-60 years and living in Rwanda were enrolled in 2010. Cervical specimens were collected and tested by careHPV, a DNA test for a pool of 14 hrHPV types. Prevalence with binomial 95% confidence intervals (95% CI) and determinants of testing hrHPV positive were calculated.
hrHPV prevalence was higher in HIV [+] (31.8%, 95% CI = 29.2-34.4%) than HIV [-] women (8.2%, 95% CI = 6.7-9.8%; P < 0.0001). Among HIV [+] women, there was a significant trend (ptrend <0.001) of higher hrHPV prevalence with lower CD4 cell count, with the highest hrHPV prevalence among those with <200 CD4 cell counts (45.5%, 95% CI = 34.8-56.4%). In multivariate analysis of HIV [+] women, testing hrHPV positive was positively associated CD4 count of <200 cells/μL, history of 3 or more sexual partners, and history of using hormonal contraception, and negatively associated with older age. In HIV [-] women, testing hrHPV positive was negatively associated only with older age groups of 45-49 and 50-60 years and surprisingly was not associated with lifetime number of sexual partners.
hrHPV prevalence is high in HIV [+], especially in women with the lowest CD4 cell counts, which may have implications for utilizing hrHPV-based screening strategies such as screen-and-treat in these high-risk subgroups.
PMCID: PMC4413542  PMID: 25926864
HPV; HIV; Cervical cancer; Screening
16.  Insulin, Insulin-like Growth Factor-I, Endogenous Estradiol, and Risk of Colorectal Cancer in Postmenopausal Women 
Cancer research  2008;68(1):329-337.
Obesity is a risk factor for colorectal cancer, and hyperinsulinemia, a common condition in obese patients, may underlie this relationship. Insulin, in addition to its metabolic effects, has promitotic and antiapoptotic activity that may be tumorigenic. Insulin-like growth factor (IGF)-I, a related hormone, shares sequence homology with insulin, and has even stronger mitogenic effects. However, few prospective colorectal cancer studies directly measured fasting insulin, and none evaluated free IGF-I, or endogenous estradiol, a potential cofactor in postmenopausal women. Therefore, we conducted a case-cohort investigation of colorectal cancer among nondiabetic subjects enrolled in the Women’s Health Initiative Observational Study, a prospective cohort of 93,676 postmenopausal women. Fasting baseline serum specimens from all incident colorectal cancer cases (n = 438) and a random subcohort (n = 816) of Women’s Health Initiative Observational Study subjects were tested for insulin, glucose, total IGF-I, free IGF-I, IGF binding protein-3, and estradiol. Comparing extreme quartiles, insulin [hazard ratio (HR)q4–q1, 1.73; 95% confidence interval (CI), 1.16–2.57; ptrend = 0.005], waist circumference (HRq4–q1, 1.82; 95% CI, 1.22–2.70; ptrend = 0.001), and free IGF-I (HRq4–q1, 1.35; 95% CI, 0.92–1.98; Ptrend = 0.05) were each associated with colorectal cancer incidence in multivariate models. However, these associations each became nonsignificant when adjusted for one another. Endogenous estradiol levels, in contrast, were positively associated with risk of colorectal cancer (HR comparing high versus low levels, 1.53; 95% CI, 1.05–2.22), even after control for insulin, free IGF-I, and waist circumference. These data suggest the existence of at least two independent biological pathways that are related to colorectal cancer: one that involves endogenous estradiol, and a second pathway broadly associated with obesity, hyperinsulinemia, and free IGF-I.
PMCID: PMC4225702  PMID: 18172327
17.  The Impact of HIV Status, HIV Disease Progression and Post-Traumatic Stress Symptoms on the Health-Related Quality of Life of Rwandan Women Genocide Survivors 
We examined whether established associations between HIV disease and HIV disease progression on worse health-related quality of life (HQOL) were applicable to women with severe trauma histories, in this case Rwandan women genocide survivors, the majority of whom were HIV infected. Additionally, this study attempted to clarify whether post-traumatic stress symptoms were uniquely associated with HQOL or confounded with depression.
The Rwandan Women’s Interassociation Study and Assessment (RWISA) was a longitudinal prospective study of HIV-infected and uninfected women. At study entry 922 women (705 HIV+ and 217 HIV−) completed measures of symptoms of post-traumatic stress and HQOL as well as other demographic, clinical and behavioral characteristics.
Even after controlling for potential confounders and mediators, HIV+ women, in particular those with the lowest CD4 counts, scored significantly worse on HQOL and overall QOL than did HIV− women. Even after controlling for depression and HIV disease progression, women with more post-traumatic stress symptoms scored worse on HQOL and overall QOL than women with fewer post-traumatic stress symptoms.
This study demonstrated that post-traumatic stress symptoms were independently associated with HQOL and overall QOL, independent of depression and other confounders or potential mediators. Future research should examine whether the long term impact of treatment on physical and psychological symptoms of HIV and post-traumatic stress symptoms would generate improvement in HQOL.
PMCID: PMC4084826  PMID: 23271207
Quality of Life; Posttraumatic Stress Disorder; HIV; Women; Rwanda
18.  Concurrent Partnerships and HIV Risk among Men Who Have Sex with Men in New York City 
Sexually transmitted diseases  2014;41(3):200-208.
Concurrent partnerships are a significant public health concern among men who have sex with men (MSM). This study describes the prevalence of concurrency and its association with serodiscordant/serostatus unknown unprotected anal or vaginal intercourse (SDUI) among MSM in New York City.
1,458 MSM completed a social and sexual network inventory about their male and female sex partners, including concurrency, in the last 3 months. Logistic regression identified factors associated with SDUI.
Median age was 29 years. 23.5% reported being HIV+. The men reported mean 3.2 male partners in last 3 months. 16.6% reported having recent SDUI. 63.2% described having concurrent sex partners (individual concurrency based on overlapping dates of relationships); 71.5% reported having partners whom they believed had concurrent partners (perceived partner concurrency); 56.1% reported that both they and their partners had concurrent partners (reciprocal concurrency). Among HIV+ men by self-report, having SDUI was positively associated with individual concurrency, any alcohol use during sex, having more male sex partners, and not having a main partner. Among self-reported HIV- men, having SDUI was positively associated with perceived partner concurrency, lower education level, any alcohol and drug use during sex, having more male sex partners, and having an anonymous partner.
Concurrency was common among MSM. The association of SDUI with individual and perceived partner concurrency, along with substance use during sex, having an anonymous partner, and having many sex partners likely further increases HIV acquisition and transmission risk among MSM. HIV prevention interventions should address concurrency among MSM.
PMCID: PMC4171743  PMID: 24521727
19.  A randomized trial of enhanced HIV risk reduction and vaccine trial education interventions among HIV-negative, high-risk women who use non-injection drugs: The UNITY Study 
Limited data are available on interventions to reduce sexual risk behaviors and increase knowledge of HIV vaccine trial concepts in high risk populations eligible to participate in HIV vaccine efficacy trials.
The UNITY Study was a two-arm randomized trial to determine the efficacy of enhanced HIV risk reduction and vaccine trial education interventions to reduce the occurrence of unprotected vaginal sex acts and increase HIV vaccine trial knowledge among 311 HIV-negative non-injection drug using women. The enhanced vaccine education intervention using pictures along with application vignettes and enhanced risk reduction counseling consisting of three one-on-one counseling sessions were compared to standard conditions. Follow-up visits at one week and one, six and twelve months after randomization included HIV testing and assessment of outcomes.
During follow up, the percent of women reporting sexual risk behaviors declined significantly, but did not differ significantly by study arm. Knowledge of HIV vaccine trial concepts significantly increased but did not significantly differ by study arm. Concepts about HIV vaccine trials not adequately addressed by either condition included those related to testing a vaccine for both efficacy and safety, guarantees about participation in future vaccine trials, assurances of safety, medical care, and assumptions about any protective effect of a test vaccine.
Further research is needed to boost educational efforts and strengthen risk reduction counseling among high-risk non-injection drug using women.
PMCID: PMC4154582  PMID: 20190585
HIV; vaccines; behavioral intervention; women; substance use
20.  Food Insecurity with Hunger Is Associated with Obesity among HIV-Infected and at Risk Women in Bronx, NY 
PLoS ONE  2014;9(8):e105957.
Food insecurity, insufficient quality and quantity of nutritionally adequate food, affects millions of people in the United States (US) yearly, with over 18 million Americans reporting hunger. Food insecurity is associated with obesity in the general population. Due to the increasing prevalence of obesity and risk factors for cardiovascular disease among HIV-infected women, we sought to determine the relationship between food insecurity and obesity in this cohort of urban, HIV-infected and –uninfected but at risk women.
Using a cross-sectional design, we collected data on food insecurity, body mass index and demographic and clinical data from 231 HIV-infected and 119 HIV-negative women enrolled in Bronx site of the Women’s Interagency HIV Study (WIHS). We used multivariate logistic regression to identify factors associated with obesity.
Food insecurity was highly prevalent, with almost one third of women (110/350, 31%) reporting food insecurity over the previous six months and over 13% of women reported food insecurity with hunger. Over half the women were obese with a Body Mass Index (BMI) of ≥30. In multivariate analyses, women who were food insecure with hunger had higher odds of obesity (Adjusted odds ratio [aOR] = 2.56, 95% Confidence Interval [CI] = 1.27, 5.20) after adjusting for HIV status, age, race, household status, income, drug and alcohol use.
Food insecurity with hunger was associated with obesity in this population of HIV-infected and –uninfected, urban women. Both food insecurity and obesity are independent markers for increased mortality; further research is needed to understand this relationship and their role in adverse health outcomes.
PMCID: PMC4146558  PMID: 25162598
21.  Plasma and Mucosal HIV Viral Loads Are Associated with Genital Tract Inflammation In HIV-Infected Women 
Systemic and mucosal inflammation may play a role in HIV control. A cross-sectional comparison was conducted among women in the Women’s Interagency HIV Study (WIHS) to explore the hypothesis that compared to HIV-uninfected participants, women with HIV and in particular, those with high plasma viral load (PVL) have increased levels of mucosal and systemic inflammatory mediators and impaired mucosal endogenous antimicrobial activity.
19 HIV-uninfected, 40 HIV-infected on antiretroviral therapy (ART) with PVL ≤ 2600 copies/ml (low viral load) (HIV+-LVL), and 19 HIV-infected on or off ART with PVL >10,000 (high viral load) (HIV+-HVL) were evaluated. Immune mediators and viral RNA were quantified in plasma and cervicovaginal lavage (CVL). CVL antimicrobial activity was also determined.
Compared to HIV-uninfected, HIV+-HVL women had higher levels of mucosal, but not systemic pro-inflammatory cytokines and chemokines, higher Nugent scores, and lower E. coli bactericidal activity. In contrast, there were no significant differences between HIV+-LVL and HIV-uninfected controls. After adjusting for PVL, HIV genital tract shedding was significantly associated with higher CVL concentrations of IL-6, IL-1β, MIP-1α, and RANTES and higher plasma concentrations of MIP-1α. High PVL was associated with higher CVL levels of IL-1β and RANTES, as well as with higher Nugent scores, lower E. coli bactericidal activity, smoking and lower CD4 counts; smoking and CD4 count retained statistical significance in a multivariate model.
Further study is needed to determine if the relationship between mucosal inflammation and PVL is causal and to determine if reducing mucosal inflammation is beneficial.
PMCID: PMC3706034  PMID: 23591635
HIV; HSV; mucosal immunity; inflammation; female genital tract; WIHS
23.  Association Of Hepatitis C With Markers Of Hemostasis In HIV-Infected and Uninfected Women in the Women’s Interagency HIV Study (WIHS) 
Coinfection with human immunodeficiency virus (HIV) and hepatitis C virus (HCV) is common. HIV infection and treatment are associated with hypercoaguability; thrombosis in HCV is under-investigated. Proposed markers of hemostasis in HIV include higher D-dimer, Factor VIII% and Plasminogen Activator Inhibitor-1 (PAI-1Ag), and lower total Protein S% (TPS), but have not been examined in HCV. We assessed the independent association of HCV with these four measures of hemostasis in a multicenter, prospective study of HIV: the Women’s Interagency HIV Study (WIHS).
We randomly selected 450 HCV-infected (anti-HCV+ with detectable plasma HCV RNA) and 450 HCV-uninfected (anti-HCV−) women. HCV was the main exposure of interest in regression models.
443 HCV+ and 425 HCV− women were included. HCV+ women had higher Factor VIII% (124.4% ±3.9 vs. 101.8% ±3.7, p <0.001) and lower TPS (75.7% ±1.1 vs. 84.3% ±1.1, <0.001) than HCV−, independent of HIV infection and viral load; there was little difference in PAI-1Ag or log10 D-dimer. After adjustment for confounders, these inferences remained. HIV infection was independently associated with higher Factor VIII% and log10 D-dimer, and lower TPS.
HCV was independently associated with higher Factor VIII% and lower TPS consistent with hypercoaguability. Higher Factor VIII % and D-dimer and lower total Protein S % were also strongly associated with HIV infection and levels of HIV viremia, independent of HCV infection. Further investigation is needed to determine if there is increased thrombotic risk from HCV. Studies examining hemostasis markers in HIV infection must also assess the contribution of HCV infection.
PMCID: PMC3652915  PMID: 23221984
24.  Correlates of Unprotected Vaginal or Anal Intercourse with Women among Substance-Using Men Who Have Sex with Men 
AIDS and behavior  2013;17(3):889-899.
The role men who have sex with men and women (MSMW) play in heterosexual HIV transmission is not well understood. We analyzed baseline data from Project MIX, a behavioral intervention study of substance-using men who have sex with men (MSM), and identified correlates of unprotected vaginal intercourse, anal intercourse, or both with women (UVAI). Approximately 10% (n=194) of the men reported vaginal sex, anal sex, or both with a woman; of these substance-using MSMW, 66% (129) reported UVAI. Among substance-using MSMW, multivariate analyses found unemployment relative to full/part-time employment (OR=2.28; 95% CI 1.01, 5.17), having a primary female partner relative to no primary female partner (OR=3.44; CI 1.4, 8.46), and higher levels of treatment optimism (OR=1.73; 95% CI 1.18, 2.54) increased odds of UVAI. Strong feelings of connection to a same-race gay community (OR=0.71; 95% CI 0.56, 0.91) and Viagra use (OR=0.31; 95% CI 0.10, 0.95) decreased odds of UVAI. This work suggests that although the proportion of substance-using MSM who also have sex with women is low, these men engage in unprotected sex with women, particularly with primary female partners. This work highlights the need for further research with the substance using MSMW population to inform HIV prevention interventions specifically for MSMW.
PMCID: PMC3693735  PMID: 23229336
bisexual; heterosexual; HIV; MSMW; condom usage
25.  “Straight Talk” for African American heterosexual men: Results of a single-arm behavioral intervention trial 
AIDS care  2012;25(5):627-631.
In the United States, heterosexual transmission is the second leading cause of HIV/AIDS, and two-thirds of all heterosexually acquired cases diagnosed between 2005 and 2008 occurred among African Americans. Few HIV prevention interventions have been designed specifically for African American heterosexual men not seeking clinical treatment. Here we report results of a single-arm intervention trial of a theory-based HIV prevention intervention designed to increase condom use, reduce concurrent partnering and increase HIV testing, among heterosexually active, African American men living in high HIV prevalence areas of New York City. We tested our hypothesis using McNemar discordant pairs exact test for binary variables and paired t-tests for continuous variables. We observed statistically significant declines in mean number of total and new female partners, unprotected sex partners and partner concurrency in both primary and non-primary sex partnerships between baseline and three months post-intervention.
PMCID: PMC3693736  PMID: 23005899

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