Journal Article Annotations
2018, 3rd Quarter
Annotations by John Grimaldi, MD, and Mary Ann Cohen, MD, FACLP
Type of study: This study was a secondary analysis of an observational clinical cohort study of patients receiving medical care at a large urban US tertiary care center from 2007 to 2016.
The finding: This study comprised a secondary analysis of 245 pregnant HIV-infected and HIV-uninfected women within a larger cohort of pregnant mother-infant dyads receiving medical care at a large, urban U.S. tertiary care center from 2007-2016. Rates of depression, measured by chart review indicating a physician diagnosis of antepartum depression, were significantly greater in HIV-infected women compared to the HIV-uninfected subgroup of women, after adjusting for age, marital status, domestic violence in pregnancy, substance use and depression prior to pregnancy. Although perinatally HIV-infected women were not more likely than non-perinatally HIV-infected pregnant women to suffer from antepartum depression, the “strong association between HIV infection and depression was driven by the perinatally HIV-infected subgroup, a distinction that has not been reported on in previous studies.”
Strength and weaknesses: This study extends previous research involving antepartum depression in HIV-infected compared to HIV-uninfected pregnant women and is among the first published studies to examine depression prevalence in pregnant women with perinatally acquired HIV. It adds to our evolving understanding of possible links between depression and underlying immune dysregulation and alterations in neuroinflammation. The study’s limitations include its small sample size, reliance on chart review for a physician-documented diagnosis of depression, and the absence of data on childhood trauma, a known risk factor for both HIV infection and antepartum depression. Its location in a large urban setting limits the generalizability of its findings to other settings.
Relevance: While rates of mother-to-child HIV transmission have fallen significantly in resource-advantaged countries such as the U.S. and in Europe, perinatally acquired HIV remains prevalent in resource-limited areas. This subpopulation of women living with HIV have been studied regarding neurodevelopmental outcomes and prevalence of mood disorders. This study extends findings from this research and adds further important insights into possible neuropathologic and immune-related mechanisms underlying mood disorders in the antepartum period.
Type of study: This study was a secondary analysis of MSM participating in either a longitudinal, randomized controlled trial or demonstration project with the same intervention but delivered by a peer counsellor instead of a trained professional.
The finding: This study comprised a subgroup of 390 HIV-infected sexual minority men participating in one of two secondary HIV prevention trials: 1) Project Enhance, a randomized, controlled active intervention trial; and 2) Peer-to-Peer, a peer-delivered demonstration project involving the same intervention. Participants were followed for one year and assessed, using self-report measures at baseline and every 3 months, for the following psychosocial conditions (syndemics): childhood sexual abuse (CSA), posttraumatic stress disorder (PTSD), anxiety disorders, depression, alcohol abuse, and polysubstance and/or stimulant use. Additionally, viral load values were obtained through chart review and recorded as either detectable or undetectable at any point during the follow-up period. Using the ACTG adherence self-report questionnaire, participants were asked about antiretroviral adherence at baseline and all follow-up assessments. An exploratory factor analysis was used to create a continuous measure of non-adherence. A multilevel model approach was used to determine the longitudinal effect of syndemic conditions on non-adherence while a logistic regression model was used to examine baseline syndemics as a predictor of viral load nonsuppression. The models confirmed the main study hypothesis that “syndemic scores over time had a significant unique effect on non-adherence scores, (p<0.004) and each additional syndemic was associated with a 0.13 increase in the non-adherence score.” Similarly, each syndemic condition at baseline was “associated with a 1.27 greater odds of having a detectable viral load during the study period, (p<0.002),” an effect that was likely mediated through the impact of syndemics on non-adherence.
Strength and weaknesses: This study adds to the growing body of syndemic literature in general, and specifically as it applies to the disproportionate impact of psychosocial challenges on sexual minority men. Whereas prior syndemic research has focused on risk behaviors among HIV-uninfected men who have sex with men (MSM), this study extends findings to HIV-infected MSM, in the U.S. Additionally, the number of syndemic conditions that this study examined is greater compared to previous studies. The study employs a longitudinal design and novel approaches to operationalizing syndemics and statistical models for examining their effects. The analysis accounted for both within-person changes in syndemic scores as well as differences among participants. Study limitations included the use of data from prior intervention studies, thus limiting variables to existing datasets and requiring statistical control for differences among intervention arms. Syndemic measures utilized self-report scales which may be less reliable than in-depth assessments. Lastly, childhood sexual abuse (CSA) was included as an independent variable. CSA has been viewed by some as a life event that may contribute to later development of other co-occurring conditions rather than as a separate syndemic condition
Relevance: This study advances our understanding of the barriers faced by sexual minority men to achieving antiretroviral adherence and virologic suppression. Because MSM account for the largest group of HIV-infected individuals, identifying facilitators for engagement in care has important implications for treatment as an HIV prevention strategy. Several other treatment implications are highlighted. Addressing medication non-adherence in the context of co-occurring psychosocial conditions such as depression and substance use disorders in an integrated fashion will improve the odds of virologic suppression. Existing studies demonstrated promising results with an integrated cognitive-behavioral therapy approach to treating depression while at the same time targeting medication non-adherence. Future research should further develop therapies that integrate assistance with medication adherence and the simultaneous treatment of multiple psychosocial conditions. This study also suggests directions for future syndemic research. An additive approach that computed scores by summing the total number of syndemics experienced by each participant was used due to its clinical relevance. Future research should further examine this method relative to other approaches. The authors also emphasize the need to consider resilience factors such as distress tolerance and social supports in the future development of interventions to mitigate negative consequences of syndemic conditions.
Type of study: This study was a cross-sectional, self-report survey, using a convenience sample of HIV-infected MSM and heterosexual men recruited from community organizations and NHS clinics across the U.K. in 2015.
The finding: This study investigated and compared stigma and discrimination experienced by HIV-infected men who have sex with men (MSM), and HIV-infected heterosexual men living in the U.K. over a 12 month period using the People Living with HIV StigmaSurvey UK 2015. The final dataset consisted of a convenience sample of 1162 HIV-infected men, 969 (83%) MSM and 193 (17%) heterosexual men, recruited from community organizations and National Health Service (NHS) clinics across the U.K. Although a high proportion of all participants reported experiencing high levels of HIV-related stigma, MSM were significantly more likely to report worrying about HIV-related workplace concerns, avoiding sex due to their HIV-status, and experiencing HIV-related sexual rejection, compared to heterosexual men. Multivariate logistic regression was conducted to identify predictors of HIV-related sexual rejection among MSM and found that not being in a relationship, falling behind on bills, and engaging in chemsex were independent predictors.
Strength and weaknesses: This study characterizes the scope of an underappreciated aspect of treatment as a major HIV prevention global strategy: HIV-related stigma and sexual rejection faced by all HIV-infected men, and by MSM in particular, at a time when the large majority of MSM in the U.K. are virologically suppressed. These findings contrast with previous studies conducted in Canada and Australia which found higher levels of HIV-related stigma among heterosexual men compared to MSM. Thus, this study highlights the need for further research in this area. The participants were demographically representative of people living with HIV across the U.K. Additionally, members of the HIV community were involved with the design and dissemination of the results of the HIV StigmaSurvey UK 2015. Study limitations included its cross-sectional design, use of a convenience sample and the use of self-reported scales, including an adaptation of the Beck Depression Inventory to measure self-image. Other limitations included the lack of data about the community organizations that were recruiting sites and the difficulty separating out other factors that may contribute to stigma and discrimination such as homophobia and racism.
Relevance: The landmark Partner Study demonstrated that among HIV-serodiscordant couples there is a negligible risk of HIV transmission through condomless sex if the HIV-infected partner is virologically suppressed. This finding has been the cornerstone of the Treatment-as-Prevention strategy to the end the spread of HIV. Despite the scientific basis for this public health measure and documented high levels of virologic suppression in certain subpopulations of HIV-infected individuals, persistent stigma, fear and discrimination continue to negatively impact the quality of life and mental health of people living with HIV (PLWH). The HIV StigmaSurvey UK 2015 study confirms and quantifies this harmful effect, the ways in which MSM and heterosexual are differentially affected, and expands on previous research on the association between stigma on the one hand, and depression, lower social support and suicide risk in PLWH on the other hand. These findings point to the need for heightened public education about the benefits of HIV treatment and associated reduced risk of transmission. Public awareness of modes of HIV transmission and the availability of effective therapies has helped reduce fear and stigma in general. More robust public health campaigns targeting MSM as well as other social and professional settings about Undetectable=Untransmittable (U=U) may further mitigate discrimination experienced by PLWH.