The Detrimental Effect of Adversity on HIV Outcomes in the Era of Combined Anti-Retroviral Therapy

Corrado Cancedda, Katherine S. Eddens, Olumuyiwa Adebona, Revathi Ravi, Enbal Shacham, Edgar Turner Overton

Department of Global Health and Social Medicine, Harvard Medical School, Boston, USA.
Division of Global Health Equity, Brigham and Women’s Hospital, Harvard Medical School, Boston, USA.
Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, USA.
George Warren Brown School of Social Work, Washington University in St. Louis, St. Louis, USA.
Texas Tech University Health Sciences Center, Lubbock, USA.

DOI: 10.4236/wja.2012.24045                

Abstract

Socially disadvantaged individuals with HIV experience unacceptably high rates of AIDS and death. The authors developed an adversity index to quantify the impact of demographic and psychosocial factors on HIV care. This retrospective cohort study included 431 participants with HIV on combined antiretroviral therapy between 2000 and 2005. Poor outcome was defined as progression to AIDS, death, virologic failure, or CD4 < 200 cells/μl at six months. The index utilized eight demographic and psychosocial variables independently associated with poor outcome. Exposure to higher numbers of variables in the adversity index significantly increased the rates of poor outcome from 14% (exposure to no variables) to 100% (exposure to seven variables). The odds of poor outcome decreased but remained significant after adjusting for adherence-defining variables, indicating a possible mediating effect of poor adherence. Durably effective therapeutic strategies must include addressing adverse demographic and psychosocial factors affecting people living with HIV.

Keywords

HIV; Outcomes; Psychosocial; Adversity; Adherence

Conflicts of Interest

The authors declare no conflicts of interest.

References

[1]	C. Liu, L. Johnson, D. Ostrow, et al., “Predictors for Lower Quality of Life in the HAART Era among HIV-Infected Men,” Journal of Acquired Immune Deficiency Syndromes, Vol. 42, No. 4, 2006, pp. 470-477. doi:10.1097/01.qai.0000225730.79610.61
[2]	C. J. Colvin, “HIV/AIDS Chronic Diseases and Globalization,” Globalization and Health, Vol. 7, No. 31, 2011. http://www.globalizationandhealth.com/content/7/1/31
[3]	CDC, “Epidemiology of HIV/AIDS—United States, 1981-2005,” Morbidity and Mortality Weekly Report, Vol. 55, No. 21, 2006, pp. 589-592.
[4]	M. Thompson, J. Aberg, P. Cahn, et al., “Antiretroviral Treatment of Adult HIV Infection: 2010 Recommendations of the International AIDS Society-USA Panel,” Journal of the American Medical Association, Vol. 304, No. 3, 2010, pp. 321-333. doi:10.1001/jama.2010.1004
[5]	D. Lai and R. J. Hardy, “An Update on the Impact of HIV/AIDS on Life Expectancy in the United States,” AIDS, Vol. 18, No. 12, 2004, pp. 1727-1740. doi:10.1097/01.aids.0000131383.15232.95
[6]	F. J. Palella, K. M. Delaney, A. C. Moorman, et al., “Declining Morbidity and Mortality among Patients with Advanced Human Immunodeficiency Virus Infection,” The New England Journal of Medicine, Vol. 339, No. 6, 1998, pp. 405-406. doi:10.1056/NEJM199808063390612
[7]	J. M. Karon, P. L. Fleming, R. W. Steketee, et al., “HIV in the United States at the Turn of the Century: An Epidemic in Transition,” American Journal of Public Health, Vol. 91, No. 7, 2001, pp. 1060-1068. doi:10.2105/AJPH.91.7.1060
[8]	E. L. Murphy, A. C. Collier, L. A. Kalish, et al., “Highly Active Antiretroviral Therapy Decreases Mortality and Morbidity in Patients with Advanced HIV Disease,” Annals of Internal Medicine, Vol. 135, No. 1, 2001, pp. 17-26.
[9]	G. Chander, S. Himelhoch and R. D. Moore, “Substance Abuse and Psychiatric Disorders in HIV-Positive Patients Epidemiology and Impact on Antiretroviral Therapy,” Drugs, Vol. 66, No. 6, 2006, pp. 769-789. doi:10.2165/00003495-200666060-00004
[10]	CDC, “HIV Surveillance Report, 2009,” Vol. 21, 2011. http://www.cdc.gov/hiv/surveillance/resources/reports/2009report/
[11]	K. Anastos, M. F. Schneider, S. J. Gange, et al., “The Association of Race, Sociodemographic, and Behavioral Characteristics with Response to Highly Active Antiretroviral Therapy in Women,” Journal Acquired Immune Deficiency Syndromes, Vol. 39, No. 5, 2005, pp. 537-544.
[12]	CDC, “Establishing a Holistic Framework to Reduce Iniquities in HIV, Viral Hepatitis, STDs and Tuberculosis in the United States,” Department of Health and Human Services, Atlanta, 2010.
[13]	E. Losina, B. Schackman, S. Sadownik, et al., “Racial and Sex Disparities in Life Expectancy Losses among HIV-Infected Persons in the United States: Impact of Risk Behavior, Late Initiation, and Early Discontinuation of Antiretroviral Therapy,” Clinical Infectious Diseases, Vol. 49, No. 10, 2009, pp. 1570-1578. doi:10.1086/644772
[14]	W. Pence, J. Ostermann, V. Kumar, et al., “The Influence of Psychosocial Characteristics and Race/Ethnicity on the Use, Duration, and Success of Antiretroviral Therapy,” Journal Acquired Immune Deficiency Syndrome, Vol. 47, No. 2, 2008, pp. 194-201. doi:10.1097/QAI.0b013e31815ace7e
[15]	E. Shacham, D. Nurutdinova, N. Onen, et al., “The Interplay of Sociodemographic Factors on Virologic Suppression among a US Outpatient HIV Clinic Population,” AIDS Patient Care STDS, Vol. 24, No. 4, 2010, pp. 229-235. doi:10.1089/apc.2009.0275
[16]	A. L. Meditz , S. MaWhinney, A. Allshouse, et al., “Sex, Race and Geographic Region Influence Clinical Outcomes of Interest Following Primary HIV-1 Infection,” Journal of Infectious Diseases, Vol. 203, No. 4, 2011, pp. 442-451. doi:10.1093/infdis/jiq085
[17]	D. C. Lemly, B. E. Shepherd, T. Hulgan, et al., “Race and Sex Differences in Antiretroviral Therapy Use and Mortality among HIV-Infected Persons in Care,” Journal of Infectious Diseases, Vol. 199, No. 7, 2009, pp. 991-998. doi:10.1086/597124
[18]	D. A. Rastegar, M. I. Fingerhood and D. R. Jasinski, “Highly Active Antiretroviral Therapy Outcomes of Interest in a Primary Care Clinic,” AIDS Care: Psychological and Socio-Medical Aspects of AIDS/HIV, Vol. 15, No. 2, 2003, pp. 231-237.
[19]	H. D. Dean, C. B. Steele, A. J. Satcher, et al., “HIV/AIDS among Minority Races and Ethnicities in the United States, 1999-2003,” Journal of the National Medical Association, Vol. 97, No. 7S, 2005, pp. S5-S12.
[20]	W. E. Cunningham, R. D. Hays, N. Duan, et al., “The Effect of Socioeconomic Status on the Survival of People Receiving Care for HIV Infection in the United States,” Journal of Health Care for the Poor and Underserved, Vol. 15, No. 4, 2005, pp. 655-676. doi:10.1353/hpu.2005.0093
[21]	C. Liu, K. Weber, E. Robison, et al., “Assessing the Effect of HAART on Change in Quality of Life among HIV-Infected Women,” AIDS Research and Therapy, Vol. 3, No. 6, 2006. http://www.aidsrestherapy.com/content/3/1/6
[22]	B. W. Pence, W. C. Miller, B. N. Gaynes, et al., “Psychiatric Illness and Virologic Response in Patients Initiating Highly Active Antiretroviral Therapy,” Journal of Acquired Immune Deficiency Syndromes, Vol. 44, No. 2, 2007, pp. 159-166. doi:10.1097/QAI.0b013e31802c2f51
[23]	G. Chander, B. Lau and R. D. Moore, “Hazardous Alcohol Use: A Risk Factor for Non-Adherence and Lack of Suppression in HIV Infection,” Journal of Acquired Immune Deficiency Syndromes, Vol. 43, No. 4, 2006, pp. 411-417. doi:10.1097/01.qai.0000243121.44659.a4
[24]	S. Lieb, R. G. Brooks, R. S. Hopkins, et al., “Predicting Death from HIV/AIDS: A Case-Control Study from Florida Public HIV/AIDS Clinics,” Journal Acquired Immune Deficiency Syndromes, Vol. 30, No. 3, 2002, pp. 351-358. doi:10.1097/00042560-200207010-00012
[25]	R. Goldstein, M. Johnson, M. Rotheram-Borus, et al., “Psychological Distress, Substance Use, and Adjustment among Parents Living with HIV,” Journal of American Board of Family Practice, Vol. 18, No. 5, 2005, pp. 362-373. doi:10.3122/jabfm.18.5.362
[26]	The White House, “National HIV/AIDS Strategy of the United States,” Washington DC, 2010.
[27]	M. Mitka, “Patient-Centered Medical Homes Offer a Model for Better, Cheaper Health Care,” Journal of the American Medical Association, Vol. 307, No. 8, 2012, pp. 770-771. doi:10.1001/jama.2012.180
[28]	M. Davis-Michaud, R. Yurk, D. Lansky, et al., “Quality of Care for People with HIV/AIDS: Patients’ Perspectives,” HIV Clinical Trials, Vol. 5, No. 6, 2004, pp. 406-415. doi:10.1310/GQ98-PGK7-0T97-47XH
[29]	K. Stange, P. Nutting, W. Miller, et al., “Defining and Measuring the Patient-Centered Medical Home,” Journal of General Internal Medicine, Vol. 25, No. 6, 2010, pp. 601-612. doi:10.1007/s11606-010-1291-3
[30]	SPSS 16.0 Graduate Student Version [Computer Program], Chicago, 2007.
[31]	A. Harzke, M. Ross and D. Scott, “Predictors of Post-Release Primary Care Utilization among HIV-Positive Prison Inmates: A Pilot Study,” AIDS Care: Psychological and Socio-Medical Aspects of AIDS/HIV, Vol. 18, No. 4, 2006, pp. 290-301.
[32]	J. Kowlaski, S. Gange, M. Schneider, et al., “Relationship of Injection Drug Use, Antiretroviral Therapy Resistance, and Genetic Diversity in the HIV-1 Pol Gene,” Journal of Acquired Immune Deficiency Syndromes, Vol. 50, No. 4, 2009, pp. 381-389. doi:10.1097/QAI.0b013e318198a619
[33]	G. DeLorenze, C. Weisner, A. Tsai, et al., “Excessive Mortality among HIV-Infected Patients Diagnosed with Substance Use Dependence of Abuse Receiving Care in a Fully Integrated Medical Care Program,” Alcoholism Clinical and Experimental Research, Vol. 35, No. 2, 2011, pp. 203-210. doi:10.1111/j.1530-0277.2010.01335.x
[34]	S. Mannheimer, G. Friedland, C. Child, et al., “The Consistency of Adherence to Antiretroviral Therapy Predicts Biological Outcomes of Interest for Human Immunodeficiency Virus-Infected Persons in Clinical Trials,” Clinical Infectious Diseases, Vol. 34, No. 8, 2002, pp. 1115-1121. doi:10.1086/339074
[35]	B. Turner, “Adherence to Antiretroviral Therapy by Human Immunodeficiency Virus-Infected Patients,” Journal of Infectious Diseases, Vol. 185, No. S2, 2002, pp. S143-S151. doi:10.1086/340197
[36]	F. Maggiolo, M. Airoldi, D. Hendrik, et al., “Effect of Adherence to HAART on Virologic Outcome and on the Selection of Resistance-Conferring Mutations in NNRTI- or PI-Treated Patients,” HIV Clinical Trials, Vol. 8, No. 5, 2007, pp. 282-292. doi:10.1310/hct0805-282
[37]	M. Chesney, M. Morin and L. Sherr, “Adherence to HIV Combination Therapy,” Social Science and Medicine, Vol. 50, No. 11, 2000, pp. 1599-1605. doi:10.1016/S0277-9536(99)00468-2
[38]	B. Schackman, K. Gebo, R. Walensky, et al., “The Lifetime Cost of Current Human Immunodeficiency Virus Care in the United States,” Medical Care, Vol. 44, No. 11, 2006, pp. 990-997. doi:10.1097/01.mlr.0000228021.89490.2a
[39]	P. Volberding and S. Deeks, “Antiretroviral Therapy and Management of HIV Infection,” The Lancet, Vol. 376, No. 9734, 2010, pp. 49-62. doi:10.1016/S0140-6736(10)60676-9
[40]	T. Hoang, M. Goetz, E. Yano, et al., “The Impact of Integrated HIV Care on Patient Health Outcomes of Interest,” Medical Care, Vol. 47, No. 5, 2009, pp. 560-567. doi:10.1097/MLR.0b013e31819432a0
[41]	A. Gawande, “The Hot Spotters: Can We Lower Medical Costs by Giving the Neediest Patients Better Care?” The New Yorker, January 2011, pp. 40-51.
[42]	H. Behforouz, P. Farmer and J. Mukherjee, “From Directly Observed Therapy to Accompagnateurs: Enhancing AIDS Treatment Outcomes of Interest in Haiti and in Boston,” Clinical Infectious Diseases, Vol. 38, No. S5, 2004, pp. 429S-436S. doi:10.1086/421408
[43]	M. Mitka, “Patient-Centered Medical Homes Offer a Model for Better, Cheaper Care,” Journal of the American Medical Association. Vol. 307, No. 8, 2012, pp. 770-771. doi:10.1001/jama.2012.180
[44]	R. McLellan, B. Sherman, R. Loeppke, et al., “Optimizing Healthcare Delivery by Integrating Workplaces, Homes and Communities: How Occupational and Environmental Medicine can Serve as a Vital Connecting Link between Accountable Care Organizations and the Patient-Centered Medical Home,” Journal of Occupational and Environmental Medicine, Vol. 54, No. 4, 2012, pp. 504-512. doi:10.1097/JOM.0b013e31824fe0aa
[45]	E. Fisher and S. Shortell, “Accountable Care Organizations: Accountable for What, to Whom and How,” Journal of the American Medical Association, Vol. 304, No. 15, 2010, pp. 1175-1176. doi:10.1001/jama.2010.1513
[46]	L. Marc, M. Testa, A. Walker, et al., “Educational Attainment and Response to HAART during Initial Therapy for HIV-1 Infection,” Journal of Psychosomatic Research, Vol. 63, No. 2, 2007, pp. 207-216. doi:10.1016/j.jpsychores.2007.04.009
[47]	J. Kim, P. Farmer, “AIDS in 2006—Moving toward One World, One Hope?” New England Journal of Medicine, Vol. 355, No. 7, 2006, pp. 645-647. doi:10.1056/NEJMp068166
[48]	J. Mukherjee, L. Ivers, F. Leandre, et al., “Antiretroviral Therapy in Resource-Poor Settings. Decreasing Barriers to Access and Promoting Adherence,” Journal Acquired Immune Deficiency Syndrome, Vol. 355, No. 7, 2006, pp. 123S-126S. doi:10.1097/01.qai.0000248348.25630.74