Journal Article Annotations
2021, 2nd Quarter
Annotations by John Grimaldi MD, Mary Ann Cohen MD, FAPM, Kelly Cozza MD, DFAPA, FACLP, and Luis Pereira MD
The Centers for AIDS Research Network of Integrated Clinical Systems (CNICS) cohort comprises people living with HIV who are receiving HIV primary care at one of 8 academic medical centers across the U.S. Using a subset of CNICS data, this study explored the effect of internalized stigma on retention in care. Measures included keeping the next HIV primary care appointment and attending all scheduled primary care appointments in the 12 months following stigma assessment. The higher a participant’s internalized stigma the less likely they were to adhere to scheduled appointments. Additionally, young age and black race were independently associated with poor clinic attendance.
Strengths and limitations:
This study’s strengths include its prospective design, large sample size, geographic diversity, multi-site cohort, and use of a validated measure of internalized stigma. Women and heterosexual subjects were represented. Findings may not be generalizable to the community since all clinical sites were in large academic medical centers. Not all patients who presented to the clinic completed the patient-reported measures which may have introduced selection bias. The study did not account for potentially confounding variables, such as depression and perceived social support, which may explain or modify the results.
The association between HIV stigma and adherence to antiretroviral medications has been well studied. More recently, attention has turned toward retention in care and its link to higher mortality. Existing studies have not consistently demonstrated that HIV stigma predicts engagement and retention in care. Paradoxically, in a study of mostly men who have sex with men in San Francisco, those with higher internalized stigma were more likely to sustain engagement in care. These studies were limited by their single-site location, focus on specific populations ,or retrospective design. This study fills a gap in understanding prospectively the role of internalized stigma in disrupting engagement in the continuum of HIV care. The study also suggests a target for future interventions that aim to keep patients invested in their treatment. This goal has implications not only for individual people living with HIV, but also those at risk for acquiring HIV.
Type of study:
This was a prospective, cohort study using data from participants in The Centers for AIDS Research Network of Integrated Clinical Systems (CNICS) cohort.
Using data from a baseline assessment of HIV-negative men who have sex with men (MSM) participating in a randomized controlled HIV prevention trial, this study examined associations between demographic and behavioral variables and use of pre-exposure prophylaxis (PrEP) by condomless anal sex (CAS). Reasons for PrEP non-use were also explored by CAS. 31.2% of all participants reported current daily PrEP use,7.6% reported previous PrEP use, and 61.2% had never used PrEP. 59.2% of all participants reported CAS. Significant associations were found between current PrEP use and MSM reporting CAS, being younger than 40 years old, having a 4-year college degree or higher, and identifying as gay vs bisexual or other. There were no significant associations between current PrEP use and risky drinking, problematic drug use and race/ethnicity. Engaging in CAS, younger age and higher educational attainment were also significantly associated with previous PrEP use, compared to never used PrEP. MSM who reported CAS were more likely to explain lack of insurance coverage and access as reasons for never using PrEP, compared to those without CAS. For those not reporting CAS, lower perceived risk and starting a committed relationship were prominent reasons for never using PrEP. Regarding reasons for discontinuing PrEP, more participants who reported CAS explained that they had concerns about safety. A significant proportion of participants reporting CAS who either never used or discontinued use of PrEP gave lower perceived need as a reason.
Strengths and limitations:
This study examined correlates of PrEP use across multiple sociodemographic variables and distinguished between those at higher risk from CAS and lower risk participants. The study also broke down PrEP use into current, previous, and never. These distinctions have implications for designing more focused prevention interventions based on specific concerns of different subgroups of MSM. The study sample was large and diverse and included a greater proportion of participants who are currently using PrEP compared to previous research. Limitations included reliance on recall and reporting for behavioral assessments. The reasons for PrEP non-use were limited in number and were predetermined by study design. The study was conducted in 3 large metropolitan areas thus limiting generalizability to rural and smaller urban areas.
Efforts to end the HIV epidemic in the US have strategically targeted geographic locations and subpopulations at highest risk of HIV infection. PrEP along with Treatment as Prevention (TasP) are the core prevention approaches that will determine our success. This study fulfills the need to better understand barriers to PrEP use among MSM. Although PrEP uptake has increased, it is not used frequently enough among eligible MSM needed to make a significant difference in HIV incidence rates. This study’s purpose is aligned with this goal and advances knowledge by examining sociodemographic barriers to PrEP uptake and reasons for never using or discontinuing PrEP among participants reporting CAS. These findings have important implications for public health policy, resource allocation, clinical decision making and future research. For example, among participants who reported CAS, concerns about safety were a prominent reason for discontinuing PrEP. This finding suggests the importance of all providers, including mental health clinicians, to be adequately informed to counsel patients about realistic risks of PrEP. CAS was associated with discontinuing PrEP, highlighting the importance of counselling about condom use and risk assessment at the clinical level.
Type of study:
This study used data from a baseline assessment of a randomized controlled trial of an HIV prevention-related intervention among MSM in New York City, Atlanta, and Detroit.
Psychiatric diagnostic data were extracted from the electronic medical record (EMR) of participants in the Center for AIDS Research (CFAR) Longitudinal Database at the University of Pennsylvania to determine diagnostic rates of the following psychiatric disorders: major depressive disorder (MDD) and other depression-related disorders, posttraumatic stress disorder (PTSD) and other stress-related disorders, substance-related disorders, alcohol-related disorders, insomnia-related disorders, and adjustment-related disorders. MDD was the only disorder diagnosed at a rates comparable to those described among the general population and people living with HIV (PLWH), 19.3 vs 16.2 vs 15.8-22, respectively. For all other disorders, prevalence rates were significantly lower when compared to the general population and to studies of PLWH. Prevalence rates for PTSD, insomnia and substance use disorders were approximately 10 times lower when compared to rates reported in prior literature.
Strengths and Limitations:
This is the first study of its kind to report rates of psychiatric disorders documented in the EMR of PLWH. This study used a large sample size. The psychiatric disorders chosen for investigation have been shown to be overrepresented in prior studies of PLWH compared to the general population. One limitation of the study is the lack of data extracted from the EMRs of people living without HIV. Without a comparison group, it is not possible to know whether findings may also apply more broadly to patients receiving general medical care. All participants were enrolled in studies through the Penn Center for AIDS Research and therefore findings may not be applicable to the general population of PLWH.
The benefits of early detection and treatment of psychiatric and substance- related disorders have been well-documented in previous studies. Research has demonstrated that un- and under-treated psychiatric and substance-related symptoms may be associated with suboptimal medication adherence and adherence to medical appointments, failure to achieve viral suppression, and increased morbidity and early mortality. The finding of comparable prevalence of MDD, compared to general and HIV-specific populations, may be explained by multiple factors. Better understanding these factors may inform interventions leading to improved detection and treatment of other prevalent psychiatric disorders in PLWH. Educating healthcare providers about common psychiatric conditions in PLWH and systems-level innovations should be explored. This study’s findings add to the accumulating evidence for the importance of syndemic conditions such as psychiatric and substance-related disorders, trauma, and adverse social conditions, as drivers of the U.S. HIV epidemic.
Type of study:
cross-sectional cohort study