Challenges in addressing depression in HIV research: assessment, cultural context, and methods.

Depression is one of the most common co-morbidities of HIV infection. It negatively impacts self-care, quality of life, and biomedical outcomes among people living with HIV (PLWH) and may interfere with their ability to benefit from health promotion interventions. State-of-the-science research among PLWH, therefore, must address depression. To guide researchers, we describe the main diagnostic, screening, and symptom-rating measures of depression, offering suggestions for selecting the most appropriate instrument. We also address cultural considerations in the assessment of depression among PLWH, emphasizing the need to consider measurement equivalence and offering strategies for developing measures that are valid cross-culturally. Finally, acknowledging the high prevalence of depression among PLWH, we provide guidance to researchers on incorporating depression into the theoretical framework of their studies and employing procedures that account for participants with depression.

Association between opioid use and health care utilization as measured by emergency room visits and hospitalizations among persons living with HIV.

BACKGROUND: Epidemiologic studies in the non-human immunodeficiency virus (HIV) positive population have shown greater health care utilization among persons with chronic non-cancer pain on opioid therapy. However, we are not aware of any similar data in the HIV positive population. METHODS: We evaluated health care utilization, as measured by emergency room (ER) visits and hospitalizations, among persons with HIV and chronic pain seen at an academic medical center, during the calendar year 2005. We compared these outcomes between patients on chronic opioid therapy with those not on opioids. RESULTS: In univariate models chronic opioid therapy was associated with both ER visits and hospitalization: ER visits odds ratio (OR)=2.18 (95% confidence interval [CI], 1.30-3.66), hospitalization OR=1.90 (95% CI, 1.03-3.51). After multivariate analyses only nonsignificant trends remain: ER visits OR=1.71 (95% CI, 0.95-3.08); hospitalization OR=1.28 (95% CI, 0.66-2.49). CONCLUSIONS: In our study HIV positive individuals with chronic pain were more likely to be seen in the ER and be hospitalized if they were on opioids. However, after controlling for other variables, the association with opioids no longer remained significant.

Correctional facilities as partners in reducing HIV disparities.

The United States now has the highest incarceration rate in the world. The majority of prison and jail inmates come from predominantly nonwhite and medically underserved communities. Although incarceration has adverse effects on both individual and community health, prisons and jails have also been used successfully as venues to provide health services to people with HIV who frequently lack stable health care. We review demographic trends shaping the difficulties in providing care to incarcerated people with HIV and recommend the Centers for AIDS Research Collaboration on HIV in Corrections as a model of interdisciplinary collaboration in addressing those difficulties.

Variables associated with decreasing pain among persons living with human immunodeficiency virus: a longitudinal follow-up study.

BACKGROUND: Pain is common among persons with human immunodeficiency virus (HIV); however, there are minimal data on its natural history, or the long-term efficacy of analgesic therapies. METHODS: We performed an observational study between 2001 and 2009. Pain was defined on a 0 to 10 scale; 0=no pain; 10=worst pain possible. Patients were included if they were HIV positive, had a chronic pain diagnosis, a median pain score during the first year of observation of ≥1.0, ≥2 years of follow-up, and ≥3 recorded pain scores. Two models were used to describe decreasing pain. Model 1 defined decreasing pain as a negative slope to the best fit line through all recorded pain scores. Model 2 defined decreasing pain as a median pain score of zero during the last year of follow-up. RESULTS: Using model 1, decreasing pain was negatively associated with a history of being abused (odds ratio=0.29) and positively associated with peripheral neuropathy (3.54). Using model 2, decreasing pain was positively associated with highly active antiretroviral therapy (3.71) and negatively associated with opioid analgesic use (0.24). CONCLUSIONS: We found social and HIV-related variables associated with decreasing pain. We failed to show a positive association between analgesic use and decreasing pain.

Ongoing pain despite aggressive opioid pain management among persons with HIV.

BACKGROUND: Chronic pain is a common problem among persons living with HIV and opioids are frequently used in its treatment. However, data on the variables associated with opioids use and the efficacy of this practice are lacking. METHODS: We performed a cross-sectional cohort study of self-reported pain during the year 2005 in our clinic. Patients were grouped into 3 cohorts: those receiving daily opioid therapy for chronic pain (cohort 1, n=115), those with a chronic pain diagnosis but not on daily opioid therapy (cohort 2, n=209), and those without a chronic pain diagnosis (cohort 3, n=796). RESULTS: In multivariate analysis comparing cohorts 1 and 2, patients in cohort 1 were significantly more likely to be on a benzodiazepine or gamma-aminobutyric receptor agonist [odds ratio (OR)=15.2], have injection drug use as a HIV risk factor (OR=4.27), lack private insurance (OR=3.51), have been abused (OR=3.08), have a history of AIDS (OR=2.21), and be seen more frequently (OR=1.18). Patients in cohort 1 reported significantly more pain [mean pain scores (0 to 10): 4.3 cohort 1; 1.9 cohort 2; 0.7 cohort 3], and were more likely to have pain that was of moderate or greater severity (58.6% cohort 1; 15.5% cohort 2; 4.9% cohort 3). CONCLUSIONS: Psychosocial variables and a history of AIDS were associated with opioid use in our clinic. Persons on opioids continued to experience significantly more pain than other patients in our clinic.

The impact of mental health and substance abuse factors on HIV prevention and treatment.

The convergence of HIV, substance abuse (SA), and mental illness (MI) represents a distinctive challenge to health care providers, policy makers, and researchers. Previous research with the mentally ill and substance-abusing populations has demonstrated high rates of psychiatric and general medical comorbidity. Additionally, persons living with HIV/AIDS have dramatically elevated rates of MI and other physical comorbidities. This pattern of co-occurring conditions has been described as a syndemic. Syndemic health problems occur when linked health problems involving 2 or more afflictions interact synergistically and contribute to the excess burden of disease in a population. Evidence for syndemics arises when health-related problems cluster by person, place, or time. This article describes a research agenda for beginning to understand the complex relations among MI, SA, and HIV and outlines a research agenda for the Social and Behavioral Science Research Network in these areas.