Intra-racial disaggregation reveals associations between nativity and overall survival in women with endometrial cancer.

OBJECTIVE: Prior studies have demonstrated survival differences between Black women with endometrial cancer (EC) born in the US and Caribbean. Our objective was to determine if country of birth influences EC overall survival (OS) in disaggregated subpopulations of Black women. METHODS: Using the Florida Cancer Data System, women with EC diagnosed from 1981 to 2017 were identified. Demographic and clinical information were abstracted. Women who self-identified as Black and born in the US (USB), Jamaica (JBB), or Haiti (HBB) were included. Statistical analyses were performed using chi-square, Cox proportional hazards models, and Kaplan-Meier methods with significance set at p < 0.05. RESULTS: 3817 women met the inclusion criteria. Compared to USB, JBB and HBB had more high-grade histologies, more advanced stage disease, had a greater proportion of uninsured or Medicaid insured, and had a higher proportion of women who received chemotherapy (all p < 0.05). In multivariate analyses, age (HR 1.03 [1.02-1.05]), regional stage (HR 1.52 [1.22-1.89]), distant stage (HR 3.73 [2.84-4.89]), lymphovascular space invasion (HR 1.96 [1.61-2.39]), receipt of surgery (HR 0.47 [0.29-0.75]), and receipt of chemotherapy (HR 0.77 [0.62-0.95]) were independently associated with OS. Compared to USB, Haitian nativity was an independent negative predictor of OS when evaluating all histologies together (HR 1.54 [1.18-2.00]) and for endometrioid EC specifically (HR 1.77 [1.10-2.83]). Among women with serous EC, HBB had markedly worse median OS (18.5 months [13.4-46.5]) relative to USB (29.9 months [26.3-35.9]) and JBB (41.0 months, [34.1-82.6], p = 0.013). CONCLUSION: Country of birth is associated with endometrial cancer survival in Black women, with HBB demonstrating worse outcomes.

Differences in Cervical Cancer Outcomes by Caribbean Nativity in Black and White Women in Florida.

OBJECTIVE: Racial disparities among women with cervical cancer have been reported but are understudied in Caribbean immigrants. The objective of this study is to describe the disparities in clinical presentation and outcomes between Caribbean-born (CB) and US-born (USB) women with cervical cancer by race and nativity. METHODS: An analysis of the Florida Cancer Data Service (FCDS), the statewide cancer registry, was performed to identify women diagnosed with invasive cervical cancer between 1981 and 2016. Women were classified as USB White or Black and CB White or Black. Clinical data were abstracted. Analyses were done using chi square, ANOVA, Kaplan-Meier and Cox proportional hazards models, with significance set at P < .05. RESULTS: 14 932 women were included in the analysis. USB Black women had the lowest mean age at diagnosis, while CB Black women were diagnosed at later stages of disease. USB White women and CB White women had better OS (median OS 70.4 and 71.5 months, respectively) than USB Black and CB Black women (median OS 42.4 and 63.8 months, respectively) (P < .0001). In multivariable analysis, relative to USB Black women, CB Blacks (HR .67, CI .54-.83), and CB White (HR .66, CI .55-.79) had better odds of OS. White race among USB women was not significantly associated with improved survival (P = .087). CONCLUSION: Race alone is not a determinant of cancer mortality in women with cervical cancer. Understanding the impact of nativity on cancer outcomes is crucial to improve health outcomes.

Stress, Support, and Length of Diagnosis Among Women Living with HIV/AIDS in the Southern USA, During the COVID-19 Pandemic.

Background: Health-related challenges caused and worsened by the global COVID-19 pandemic have proven broad and multifaceted, particularly for racial/ethnic minority women living with HIV (WLWH). The 2020 pandemic has affected the wellbeing and access to care for WLWH in Southeastern Florida, a region that experienced simultaneous high rates of COVID-19 and HIV. WLWH, over a short- or long-term period, likely utilize different coping mechanisms as they face these challenges. Methods: This analysis compared pandemic-related stress and support endorsed by participants attending an urban clinic in South Florida, from January through May 2021. Participants completed an adapted version of the Pandemic Stress Index (PSI). The items in the PSI assessed emotional distress, stigma, and support, and were dichotomized, as either "stress" or "support". Mann-Whitney U-test assessed differences in distributions of PSI scores (stress and support) comparing long-term survivors (≥10 years with an HIV diagnosis) to those more recently diagnosed (<10 years). Results: The cohort consisted of 63 WLWH, aged 21-71 (Mean = 42 years±12.95). The group of WLWH were almost evenly split, with 50.8% having been diagnosed in the last 10 years (short-term survivors). The high-stress group endorsed lower levels of support, compared to the low-stress group. There was a non-significant trend of higher stress scores for short-term survivors, compared to long-term survivors; and, higher support scores for long-term survivors, compared to short-term survivors. Conclusion: Results suggest a trend in long-term survivor WLWH endorsing lower stress and higher support; the contrary was found for their short-term survivor counterparts. Patterns in COVID-19 related stressors and maladaptive behaviors need further exploration to establish suitable interventions that address disparities within groups of WLWH.

Examining 5-Year Cervical Cytology Progression Among Minority Women Living With HIV and Baseline Negative Cytology.

OBJECTIVE: Women living with HIV (WLWH) have increased risk of human papillomavirus (HPV) infection, precancers, and invasive cervical cancers. This study aims to determine the rate of cervical cytologic progression and related factors in minority WLWH across 5 years. MATERIALS AND METHODS: We used our HIV clinic database, complemented with a retrospective chart review to identify WLWH with a baseline negative cervical cytology between 2009 and 2012 and 5-year follow-up. Data included race/ethnicity, age, years living with HIV, AIDS status, viral load, history of smoking, drug use, and HPV status. Multivariate logistic regression tested progression of negative cytology to low-grade/high-grade squamous intraepithelial lesions (LGSIL/HGSIL). RESULTS: Among 162 WLWH, 42% were African American, 30% non-Hispanic African Caribbean, and 26% Hispanic. At baseline, 21% had detectable viral load (>200 cp/mL), mean age was 44.8 (±11 years), and mean years living with HIV was 9.6 (±6.9). After 5 years, 19% of the cohort progressed to LGSIL/HGSIL. Human papillomavirus was detected consistently among women with cytologic changes (30% vs 7%, p < .01). Significant factors that predicted higher likelihood of progression to LGSIL/HGSIL were detection of HPV (adjusted odds ratios = 5.11 [1.31-19.93]; p = .02), and Centers for Disease Control and Prevention-defined AIDS status (adjusted odds ratios = 4.28 [1.04-17.63]; p = .04). Of the women who maintained negative cytology at 1 to 2 years (n = 102), 5 women (5%) progressed during the following 3 years before the recommended follow-up. CONCLUSIONS: Human papillomavirus detection and AIDS status were significant factors predicting progression to LGSIL/HGSIL among minority WLWH. Providers screening WLWH for cervical intraepithelial neoplasia should carefully decide screening intervals for minority populations.

The vaginal microbiome is associated with endometrial cancer grade and histology.

The human microbiome has been strongly correlated with disease pathology and outcomes, yet remains relatively underexplored in patients with malignant endometrial disease. In this study, vaginal microbiome samples were prospectively collected at the time of hysterectomy from 61 racially and ethnically diverse patients from three disease conditions: 1) benign gynecologic disease (controls, n=11), 2) low-grade endometrial carcinoma (n=30), and 3) high-grade endometrial carcinoma (n=20). Extracted DNA underwent shotgun metagenomics sequencing, and microbial α and ß diversities were calculated. Hierarchical clustering was used to describe community state types (CST), which were then compared by microbial diversity and grade. Differential abundance was calculated, and machine learning utilized to assess the predictive value of bacterial abundance to distinguish grade and histology. Both α- and ß-diversity were associated with patient tumor grade. Four vaginal CST were identified that associated with grade of disease. Different histologies also demonstrated variation in CST within tumor grades. Using supervised clustering algorithms, critical microbiome markers at the species level were used to build models that predicted benign vs carcinoma, high-grade carcinoma versus benign, and high-grade versus low-grade carcinoma with high accuracy. These results confirm that the vaginal microbiome segregates not just benign disease from endometrial cancer, but is predictive of histology and grade. Further characterization of these findings in large, prospective studies is needed to elucidate their potential clinical applications.

An Assessment of Ovarian Cancer Histotypes Across the African Diaspora.

OBJECTIVE: Ovarian cancer in Black women is common in many West African countries but is relatively rare in North America. Black women have worse survival outcomes when compared to White women. Ovarian cancer histotype, diagnosis, and age at presentation are known prognostic factors for outcome. We sought to conduct a preliminary comparative assessment of these factors across the African diaspora. METHODS: Patients diagnosed with ovarian cancer (all histologies) between June 2016-December 2019 in Departments of Pathology at 25 participating sites in Nigeria were identified. Comparative population-based data, inclusive of Caribbean-born Blacks (CBB) and US-born Blacks (USB), were additionally captured from the International Agency for Research on Cancer and Florida Cancer Data Systems. Histology, country of birth, and age at diagnosis data were collected and evaluated across the three subgroups: USB, CBB and Nigerians. Statistical analyses were done using chi-square and student's t-test with significance set at p<0.05. RESULTS: Nigerians had the highest proportion of germ cell tumor (GCT, 11.5%) and sex-cord stromal (SCST, 16.2%) ovarian cancers relative to CBB and USB (p=0.001). CBB (79.4%) and USB (77.3%) women were diagnosed with a larger proportion of serous ovarian cancer than Nigerians (60.4%) (p<0.0001). Nigerians were diagnosed with epithelial ovarian cancers at the youngest age (51.7± 12.8 years) relative to USB (58.9 ± 15.0) and CBB (59.0± 13.0,p<0.001). Black women [CBB (25.2 ± 15.0), Nigerians (29.5 ± 15.1), and USB (33.9 ± 17.9)] were diagnosed with GCT younger than White women (35.4 ± 20.5, p=0.011). Black women [Nigerians (47.5 ± 15.9), USB (50.9 ± 18.3) and CBB (50.9 ± 18.3)] were also diagnosed with SCST younger than White women (55.6 ± 16.5, p<0.01). CONCLUSION: There is significant variation in age of diagnosis and distribution of ovarian cancer histotype/diagnosis across the African diaspora. The etiology of these findings requires further investigation.

Medical Mistrust and Adherence to Care Among a Heterogeneous Cohort of Women Living with HIV, Followed in a Large, U.S. Safety Net Clinic.

Purpose: To explore the relationship between medical mistrust, as measured by the Group-Based Medical Mistrust (GBMM) scale, and HIV care adherence among a cohort of minority women receiving care in a U.S. safety net clinic. Methods: English-, Spanish-, and Haitian Creole (Creole)-speaking patients with a recent history of nonadherence to care were surveyed. Results: English speakers endorsed the highest level of mistrust, followed by Spanish speakers and Creole speakers. Creole speakers endorsed lower mistrust, lower suspicion of providers, and lower levels of "perceived health care disparities." Higher mistrust was associated significantly with lower medication adherence, and lower rates of viral suppression (nonsignificant). Conclusion: Understanding perceptions of medical care and the relationship to HIV care adherence is an important step to addressing negative health outcomes for ethnic minority women with HIV. Clinical Trial Registration Number: NCT03738410.

Pills, PrEP, and Pals: Adherence, Stigma, Resilience, Faith and the Need to Connect Among Minority Women With HIV/AIDS in a US HIV Epicenter.

Background: Ending HIV/AIDS in the United States requires tailored interventions. This study is part of a larger investigation to design mCARES, a mobile technology-based, adherence intervention for ethnic minority women with HIV (MWH). Objective: To understand barriers and facilitators of care adherence (treatment and appointment) for ethnic MWH; examine the relationship between these factors across three ethnic groups; and, explore the role of mobile technologies in care adherence. Methods: Cross-sectional, mixed-methods data were collected from a cohort of African-American, Hispanic-American and Haitian-American participants. Qualitative data were collected through a focus group (n = 8) to assess barriers and facilitators to care adherence. Quantitative data (n = 48) surveyed women on depressive symptomology (PHQ-9), HIV-related stigma (HSS) and resiliency (CD-RISC25). We examined the relationships between these factors and adherence to treatment and care and across groups. Findings: Qualitative analyses revealed that barriers to treatment and appointment adherence were caregiver-related stressors (25%) and structural issues (25%); routinization (30%) and religion/spirituality (30%) promoted adherence to treatment and care. Caregiver role was both a hindrance (25%) and promoter (20%) of adherence to treatment and appointments. Quantitatively, HIV-related stigma differed by ethnic group; Haitian-Americans endorsed the highest levels while African-Americans endorsed the lowest. Depression correlated to stigma (R = 0.534; p < 0.001) and resiliency (R = -0.486; p < 0.001). Across ethnic groups, higher depressive symptomology and stigma were related to viral non-suppression (p < 0.05)-a treatment adherence marker; higher resiliency was related to viral suppression. Among Hispanic-Americans, viral non-suppression was related to depression (p < 0.05), and among African-Americans, viral suppression was related to increased resiliency (p < 0.04). Conclusion: Multiple interrelated barriers to adherence were identified. These findings on ethnic group-specific differences underscore the importance of implementing culturally-competent interventions. While privacy and confidentiality were of concern, participants suggested additional intervention features and endorsed the use of mCARES as a strategy to improve adherence to treatment and appointments.

A Multilingual, Culturally Competent Mobile Health Intervention to Improve Treatment Adherence Among Women Living With HIV: Protocol for a Randomized Controlled Trial.

BACKGROUND: Adherence to HIV care is complex, as barriers to care are multidimensional, particularly for ethnic minority women. Mobile health (mHealth) solutions are supportive in improving HIV health care outcomes. In the United States, however, mHealth interventions are not widely implemented in public HIV clinics and have not been customized for women. There is an unmet need for culturally and linguistically appropriate mHealth interventions that address the health care needs of minority women living with HIV. OBJECTIVE: This study aims to describe a protocol investigating the feasibility of an mHealth intervention for treatment adherence among women living with HIV. This is a two-phase, mixed methods, pilot randomized controlled trial that begins with qualitative patient interviews to inform the system design. Participants will be block randomized by language (English, Spanish, and Haitian Creole) to 1 of 2 study arms. METHODS: Women (age ≥18 years) who were followed up at the women's HIV clinic of an academic medical center, with a recent history of nonadherence to HIV care (missed appointments, unsuppressed viral load, or not taking medications as prescribed), will be enrolled. The experimental arm will receive the intervention, which includes health reminders and psychoeducational messaging, plus clinical standard of care reminders. The psychoeducational messaging will target patient-level barriers of HIV stigma and medical mistrust and resilience as a patient-level strength. The control arm will receive standard of care reminders only (ie, mailed appointments and automated telephone calls). All aspects of the study and intervention will be offered in the participants' preferred language. The primary outcome is the feasibility and acceptability of the study. The secondary outcomes are changes in self-reported medication adherence, depression symptoms, HIV stigma, medical mistrust, resilience, and clinic attendance and viral suppression extracted from the participants' medical records. Data will be assessed at baseline (T0) and 2 subsequent clinic visits-approximately 3 to 4 months from the baseline (time 1; T1) and 6 to 9 months from the baseline (time 2; T2). Qualitative data will be transcribed and analyzed iteratively. Bivariate analyses will compare data by the study group (chi-square, odds ratios, and t tests). Exploratory analyses will be conducted for each outcome variable-T1 and T2 values will be compared with values at T0 by the study group. RESULTS: As of March 2020, baseline quantitative data were collected on 54 participants (28 English speakers, 14 Spanish speakers, and 12 Haitian Creole speakers). The first 3 focus groups (1 in each of the 3 languages) were completed, with a total of 20 participants. The findings are currently being integrated into the beta version of the mHealth texting system. CONCLUSIONS: The findings of this novel HIV adherence intervention may shed light on the barriers and facilitators of HIV health care and the mechanisms of an mHealth intervention that is customized for ethnic minority women living with HIV. TRIAL REGISTRATION: ClinicalTrials.gov NCT03738410; https://clinicaltrials.gov/ct2/show/NCT03738410. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/17656.

Digitized HIV/AIDS Treatment Adherence Interventions: A Review of Recent SMS/Texting Mobile Health Applications and Implications for Theory and Practice.

BACKGROUND: Mobile health technologies (mHealth) are efficacious along the continuum of HIV/AIDS-from prevention of HIV transmission to those at the highest risk of acquiring infection, to adherence to HIV medical care, for those living with the disease-decreasing the public health burden of the disease. HIV/AIDS is a complex condition, as certain population subgroups are disproportionately affected. Furthermore, barriers experienced at the individual level (e.g., HIV stigma) and at the systems level (i.e., access to care) contribute to these disparities. Low cost, high penetration rates and ease of use mean mHealth SMS/texting solutions hold the biggest promise for curbing the global HIV/AIDS epidemic; yet these technologies have their own challenges. Our primary objective was to assess interventions that promote adherence, which are delivered via SMS/texting, and important design and ethical considerations of these technologies. Specifically, we evaluated the underlying frameworks underpinning intervention design, strategies to safeguard privacy and confidentiality, and measures taken to ensure equity and equitable access across different subgroups of persons living with HIV (PLWH). We also synthesized study outcomes, barriers/facilitators to adherence, and barriers/facilitators of technology to support HIV adherence. METHODS: A scoping review methodology was utilized, searching the Medline database for recently published articles (January 2017 to June 2019). Two reviewers independently screened titles and abstracts for relevancy using the following eligibility criteria: (a) original research or protocol; (b) inclusion of persons living with HIV; (c) intervention delivery via SMS/text messaging; and, (d) intervention included HIV care adherence. RESULTS: Seven (7) of the 134 articles met full criteria. The great majority (n = 6) did not report whether the interventions were developed under established behavioral change models or frameworks. Strategies to address privacy, confidentiality and equity/equitable access were taken in four (n = 4) studies. CONCLUSION: Our mixed methods review determined that privacy and confidentiality remain a concern for PLWH. Provisions to accommodate literacy, infrastructure, technology and other challenges (e.g., access to smartphones and Wifi) are important ethical considerations that guarantee equity and equitable access. Further investigation will determine the contexts within which theoretical models and frameworks remain relevant in the rapidly evolving field of digitized interventions that support adherence.