The Relationship of Vaccine Uptake and COVID-19 Infections Among Nursing Home Staff and Residents in Missouri: A Measure of Risk by Community Mobility.

BACKGROUND: As the COVID-19 pandemic progressed across the United States, older adults living in nursing home (NH) facilities were disproportionately affected because of living in communal spaces with close proximity to others, age-related medical conditions, and constant contact with staff who may support multiple clients and facilities. While these populations are particularly at risk, there has been limited research focused on the management of the potential vectors of COVID-19 infection. METHODS: Data from the Centers for Medicare & Medicaid Services (CMS) COVID-19 reporting system assessing weekly observations of COVID-19 case counts among NH residents and COVID-19 vaccination rates among NH staff and residents in the states of Missouri and Illinois (n = 877) from May 24, 2021, to August 28, 2021, were used. This ecological study, using results from the CMS COVID-19 reporting system, local COVID-19 rates, and NH-level demographic characteristics, conducted a zero inflation mode to determine the association between NH staff vaccine uptake and COVID-19 cases among NH residents. RESULTS: Among the total 11 195 weekly observations within the NH facilities, zero cases of COVID-19 were reported during 10 683 (95%) of those weeks, supporting the use of a zero-inflated model. Results show that staff vaccination rates were significantly associated with a decrease in COVID-19 mortality. This study identified that for every percentage increase in staff vaccine coverage, the rate of COVID-19 among residents decreased by 2%. DISCUSSION: These findings suggest that NH staff vaccination rates are significantly associated with the rate of COVID-19 outbreaks among NH residents. Community median income was associated with an increased likelihood of infection. Future research that explores associations with employment benefits and staff mobility, particularly in vulnerable populations, should be implemented in future vaccination strategic planning.

Implementing Geospatial Science and Technology to Get to Zero New HIV Infections.

PURPOSE OF REVIEW: Tremendous advancements have been made in HIV treatment and prevention during the last 40 years that zero new HIV cases has become an attainable goal declared by international agencies. However, new cases of HIV infection persist. RECENT FINDINGS: The emerging field of geospatial science is positioned to play key role in the reduction of continued HIV incidence through technology-driven interventions and innovative research that gives insights into at-risk populations. As these methods become more utilized, findings consistently show the important role of location and environment plays in HIV incidence and treatment adherence. This includes distance to HIV provider, locations of where HIV transmissions occurs compared to where people with HIV reside, and how geospatial technology has been leveraged to identify unique insights among varying groups of those at increased risk for HIV, among others. Given these insights, leveraging geospatial technology would play a prominent role in achieving zero new cases of HIV infections.

Personal Location as Health-Related Data: Public Knowledge, Public Concern, and Personal Action.

OBJECTIVES: Personal health information (PHI), including health status and behaviors, are often associated with personal locations. Smart devices and other technologies routinely collect personal location. Therefore, technologies collecting personal location do not just create generic questions of privacy, but specific concerns related to PHI. METHODS: To assess public opinion on the relationship between health, personal location, and privacy, a national survey of US residents was administered online in March 2020. Respondents answered questions about their use of smart devices and knowledge of location tracking. They also identified which of the locations they could visit were most private and how to balance possibilities that locations may be private but can also be useful to share. RESULTS: Of respondents that used smart devices (n = 688), a majority (71.1%) indicated they knew they had applications tracking their location, with respondents who were younger (P < .001) and male (P = .002) and with more education (P = .045) more likely to indicate "yes." When all respondents (N = 828) identified the locations on a hypothetical map they felt were most private, health-related locations (substance use treatment center, hospital, urgent care) were the most selected. CONCLUSIONS: The historical notion of PHI is no longer adequate and the public need greater education on how data from smart devices may be used to predict health status and behaviors. The COVID-19 pandemic brought increased attention to personal location as a tool for public health. Given healthcare's dependence upon trust, the field needs to lead the conversation and be viewed as protecting privacy while usefully leveraging location data.

Examining Increasing Racial Inequities in Opioid Overdose Deaths: a Spatiotemporal Analysis of Black and White Decedents in St. Louis, Missouri, 2011-2021.

The third wave of the opioid overdose crisis-defined by the proliferation of illicit fentanyl and its analogs-has not only led to record numbers of overdose deaths but also to unprecedented racial inequities in overdose deaths impacting Black Americans. Despite this racialized shift in opioid availability, little research has examined how the spatial epidemiology of opioid overdose death has also shifted. The current study examines the differential geography of OOD by race and time (i.e., pre-fentanyl versus fentanyl era) in St. Louis, Missouri. Data included decedent records from the local medical examiners suspected to involve opioid overdose (N = 4420). Analyses included calculating spatial descriptive analyses and conducting hotspot analyses (i.e., Gettis-Ord Gi*) stratified by race (Black versus White) and time (2011-2015 versus 2016-2021). Results indicated that fentanyl era overdose deaths were more densely clustered than pre-fentanyl era deaths, particularly those among Black decedents. Although hotspots of overdose death were racially distinct pre-fentanyl, they substantially overlapped in the fentanyl era, with both Black and White deaths clustering in predominantly Black neighborhoods. Racial differences were observed in substances involved in cause of death and other overdose characteristics. The third wave of the opioid crisis appears to involve a geographic shift from areas where White individuals live to those where Black individuals live. Findings demonstrate racial differences in the epidemiology of overdose deaths that point to built environment determinants for future examination. Policy interventions targeting high-deprivation communities are needed to reduce the burden of opioid overdose on Black communities.

Prior Heterologous Flavivirus Exposure Results in Reduced Pathogenesis in a Mouse Model of Zika Virus Infection.

The 2015/2016 Zika virus epidemic in South and Central America left the scientific community urgently trying to understand the factors that contribute to Zika virus pathogenesis. Because multiple other flaviviruses are endemic in areas where Zika virus emerged, it is hypothesized that a key to understanding Zika virus disease severity is to study Zika virus infection in the context of prior flavivirus exposure. Human and animal studies have highlighted the idea that having been previously exposed to a different flavivirus may modulate the immune response to Zika virus. However, it is still unclear how prior flavivirus exposure impacts Zika viral burden and disease. In this murine study, we longitudinally examine multiple factors involved in Zika disease, linking viral burden with increased neurological disease severity, weight loss, and inflammation. We show that prior heterologous flavivirus exposure with dengue virus type 2 or 3 or the vaccine strain of yellow fever provides protection from mortality in a lethal Zika virus challenge. However, reduction in viral burden and Zika disease varies depending on the infecting primary flavivirus; with primary Zika virus infection being most protective from Zika virus challenge, followed by dengue virus 2, with yellow fever and dengue virus 3 protecting against mortality but showing more severe disease. This study demonstrates the variation in protective effects of prior flavivirus exposure on Zika virus pathogenesis and identifies distinct relationships between primary flavivirus infection and the potential for Zika virus disease. IMPORTANCE The emergence and reemergence of various vector-borne diseases in recent years highlights the need to understand the mechanisms of protection for each pathogen. In this study, we investigated the impact of prior exposure to Zika virus, dengue virus serotypes 2 or 3, or the vaccine strain of yellow fever on pathogenesis and disease outcomes in a mouse model of Zika virus infection. We found that prior exposure to a heterologous flavivirus was protective from mortality, and to varying degrees, prior flavivirus exposure was protective against neurological disease, weight loss, and severe viral burden during a lethal Zika challenge. Using a longitudinal and cross-sectional study design, we were able to link multiple disease parameters, including viral burden, with neurological disease severity, weight loss, and inflammatory response in the context of flavivirus infection. This study demonstrates a measurable but varied impact of prior flavivirus exposure in modulating flavivirus pathophysiology. Given the cyclic nature of most flavivirus outbreaks, this work will contribute to the forecasting of disease severity for future outbreaks.

Disparities in health behaviors and outcomes at the intersection of race and sexual identity among women: Results from the 2011-2016 National Health and Nutrition Examination Survey.

The purpose of this study was to explore potential differences in health behaviors and outcomes of sexual minority women (SMW) of color compared to White SMW, heterosexual women of color, and White heterosexual women. Data from 4878 women were extracted from the 2011 to 2016 National Health and Nutritional Examination Survey. The four-category independent variable (SMW of color, White SMW, heterosexual women of color, and White heterosexual women) was included in binary and multinomial logistic regression models predicting fair/poor self-reported health status, depression, cigarette smoking, alcohol, cannabis, and illicit drug use. Compared to White heterosexual women, SMW of color and heterosexual women of color had significantly higher odds of fair/poor self-reported health and lower odds of being a current or former smoker, binge drinking or using alcohol in the past year, being a former cannabis user, and ever using illicit drugs. In contrast, White SMW had significantly greater odds of depression, current smoking and cannabis and illicit drug use. Results of post-hoc tests indicated that the adjusted ORs for SMW of color differed significantly from those of White SMW for all outcomes, and did not differ significantly from those for heterosexual women of color for any outcome other than no binge drinking (OR = 0.34 vs. 0.67, p < 0.01) and current cannabis use (OR = 0.93 vs. 0.44, p < 0.01). SMW of color are more similar to heterosexual women of color than to White SMW in terms of depression, substance use, and self-reported health.

What a Difference a Drink Makes: Determining Associations Between Alcohol-Use Patterns and Condom Utilization Among Adolescents.

This study aimed to identify differences in condom use among adolescents by alcohol consumption patterns using the 2017 Youth Risk Behavior Survey. Results suggest significant increased risk of condomless sex among binge drinking youth. Surprisingly, no significant difference in condom utilization was identified between non-drinkers and only moderate drinkers. Findings highlight the need to tailor STI preventative measures accordingly.

The Impact of Clinic Policy Attendance and the Ryan White HIV/AIDS Medical Case Management Program on HIV Clinical Outcomes: A Retrospective Longitudinal Study.

Clinic appointment attendance is a significant determinant of improved HIV health outcomes. A retrospective longitudinal analysis from 2009 to 2015 examined the relationship of clinic policy attendance with and without medical case management (MCM) on HIV clinical outcomes. Clinical parameters were abstracted across the study years and latent growth models measured HIV clinical outcomes as a function of time. A total of 2773 patients were included in this study. More than the majority of individuals had 75% clinic policy attendance during each of the study years and the median number of MCM contact visits with the case manager was 4.0 visits per year (p < 0.01). While the overall trend identified improved HIV clinical outcomes across the clinic population over the study period, it also revealed individuals receiving MCM and with 75% clinic policy attendance had significantly faster improvement in HIV clinical outcomes compared to the individuals who did not receive MCM nor had 75% clinic policy attendance. This study identified how MCM, in combination with clinic policy attendance efforts, are useful in quickly improving HIV viral load and CD4 T-cell count. These findings support the continued need for funding of the Ryan White Care Act as it assists with the support of MCM and appointment attendance through the guidance of wrap-around services.

Testing the Feasibility of Using Ecological Momentary Assessment to Collect Real-Time Behavior and Mood to Predict Technology-Measured HIV Medication Adherence.

Identifying distinct patterns of behavior and mood in natural environments that interrupt medication adherence among individuals with HIV will be useful in informing intervention development. This pilot study assessed the initial efficacy of using ecologic momentary assessment to define patterns of alcohol use, mood, and medication adherence. Participants reported intraday alcohol use and mood using app-enabled smartphones and MEMSCap pill bottles to measure medication adherence. There were 34 enrolled participants, 29 of whom completed the 28-day study. Participants drank a mean of 7.75 days of the study period. The positive and negative affect scores ranged from 10 to 50, with a mean of 25.7 and 11.4 for each, respectively. The average medication adherence for the sample was 94.1%. These findings suggest these types of data collection methods are increasingly acceptable in measuring real-time mood and behavior, which may better inform interventions addressed at increasing HIV adherence practices.

Determinants of organ donation registration.

Rates of organ donor registration range from 20% to 60% throughout the United States. The purpose of this study was to examine sociogeographic differences in organ donor registration rates throughout Missouri to identify varying patterns The organ donor registration rate from each Department of Motor Vehicle office in Missouri was extracted from the National Organ Registration database, office locations were geocoded, and census tract level sociodemographic characteristics were extracted. Spatial regression analyses were conducted to identify relationships between location of DMV offices and census tract-level concentrated disadvantage. Census tract-level concentrated disadvantage (education attainment, poverty, single-headed households) had a significant negative relationship with organ donor registration rates. Yet, census tract-level African American/Black resident concentration was not significantly related to organ donor registration rates. These findings suggest that race-based interventions to recruit organ donors may no longer be necessary. Yet, identifying how characteristics of concentrated disadvantage may be more influential in determining organ donor registration. Gaining a better understanding of how individual decisions are made is integral in the context of increased life expectancy in conjunction with the complex management of chronic conditions.

The Impact of the Ryan White HIV/AIDS Medical Case Management Program on HIV Clinical Outcomes: A Longitudinal Study.

Medical case management (MCM) is a core medical service in The Ryan White HIV/AIDS Program and aims to provide treatment and care for people living with HIV/AIDS by engaging, identifying and eliminating barriers to HIV care. Little research has examined the impact of this intervention; therefore, the purpose of this study was to examine the how MCM affects HIV clinical outcomes. The study took place at a midwestern, outpatient infectious diseases clinic. This study utilized a longitudinal, retrospective study design to analyze to the impact of MCM engagement on HIV clinical outcomes (viral loads, CD4 counts) from 2009 to 2015 as a time-varying predictor. A total of 2773 patients were included in this study, of which 975 patients (35.2%) engaged in MCM. Among those in MCM, approximately 90% of the population were between 25 and 64 years of age, more than three-quarters were African American men, mean time of HIV care engagement in at this clinic care was 3.2 (± 4.1), while mean years living with HIV was 10.5 (± 7.1). Throughout the study period, those engaged in MCM had a significantly faster improvement in their HIV clinical outcomes compared to the non-MCM group (p < 0.001). The study highlights the significant impact MCM services have on improving CD4 T cell counts and HIV viral loads. The successful care coordination that MCM offers clearly improves health outcomes while creating a network of patient care.

Enhancing Adherence to Care in the HIV Care Continuum: The Barrier Elimination and Care Navigation (BEACON) Project Evaluation.

Interventions are needed to address each phase of the HIV care continuum in order to improve health outcomes and reduce likelihood of HIV transmission. The purpose of this study was to assess the impact of a community- and clinic-based intervention designed and implemented to reengage individuals who were lost to HIV care. Eligible participants had either never engaged in HIV care or had not had a medical visit for at least 12 months. Participants enrolled in a community- and clinic-based intervention that included intensive case management, access to a community nurse and peer navigator, as well as emergency stabilization funds. Data were collected at baseline and 6-month time points by the case managers; which included sociodemographics, general health, abstracted HIV viral loads and CD4 cell counts from their medical records. Descriptive and GEE analyses were conducted to assess changes from baseline to 6 months. A total of 322 participants enrolled over a 5-year period, of whom the majority were male (n = 250) and African American with a mean age of 42.0 years. After 6 months of the intervention, there was a significant increase of individuals who had undetectable HIV viral loads and their median CD4 cell counts increased (p < 0.01 for both). General health improved as well (p < 0.01). It is clear that this method of engagement, while staff intensive, is successful at engaging and retaining individuals in HIV care at least through 6 months.

Potential High-Risk Areas for Zika Virus Transmission in the Contiguous United States.

OBJECTIVES: To understand where transmission of Zika virus has the highest likelihood to occur in the contiguous United States with regard to its transmission both sexually and via Aedes aegypti mosquito bites. METHODS: We evaluated the 2 routes of transmission risk with predictors of sexually transmitted infections (percentage women of childbearing age, birthrate, gonorrhea and chlamydia rates, concentrated disadvantage) as a surrogate for unprotected sexual activity and the demographic distribution of the A. aegypti mosquito across 3108 counties in the contiguous United States. RESULTS: We found that 507 counties had the highest risk of virus exposure via mosquito vector or unprotected sexual activity; these were concentrated in southern states extending northward along the Atlantic coast and southern California, with the highest predicted risk in Mississippi counties. CONCLUSIONS: Identifying areas with higher transmission risk can inform prevention strategies and vector control, and assist in planning for diagnosis and treatment.

Challenges to HIV management among youth engaged in HIV care.

Regardless of medical advancements, new HIV infections persist. Young adults are most often newly infected, thus research is needed to assess medication adherence barriers specific to young adults with HIV. The data were abstracted from medical charts to include both self-reported behavioral and psychological distress data and HIV parameters in 2013 among patients aged 18-30 years. Descriptive and logistic regression analyses were conducted to identify factors related to viral suppression and sexually transmitted infection (STI) status. A total of 335 individuals presented for care during a 12-month period at a single clinic. The majority were African American and had a mean age of 25.6 years. Nearly all had current prescriptions of antiretroviral therapy (ART). Among those receiving ART, almost three-quarters were virally suppressed, as measured by 200 copies/mL. STI tests are conducted annually and by assessed need; 30% of this sample had at least 1 bacterial STI diagnosis within the last year. Psychological distress symptoms were more common among individuals who were not virally suppressed, compared to those who were virally suppressed. Women and individuals with moderate to severe symptoms of depression had higher odds of having unsuppressed viral loads. The independent factors associated with having any STIs were being African American or other minorities and having two or more sex partners. Our findings related to how young adults are managing their HIV care suggest that increased efforts aimed to prevent additional STIs and manage psychological distress will likely reduce transmission risks.

Exploring Characteristics and Health Care Utilization Trends Among Individuals Who Fall in the Health Insurance Assistance Gap in a Medicaid Nonexpansion State.

States that did not expand Medicaid under the Affordable Care Act (ACA) in the United States have seen a growth in the number of individuals who fall in the assistance gap, defined as having incomes above the Medicaid eligibility limit (≥44% of the federal poverty level) but below the lower limit (<100%) to be eligible for tax credits for premium subsidies or cost-sharing reductions in the marketplace. The purpose of this article is to present findings from a secondary data analysis examining the characteristics of those who fell in the assistance gap ( n = 166) in Missouri, a Medicaid nonexpansion state, by comparing them with those who did not fall in the assistance gap ( n = 157). Participants completed online demographic questionnaires and self-reported measures of health and insurance status, health literacy, numeracy, and health insurance literacy. A select group completed a 1-year follow-up survey about health insurance enrollment and health care utilization. Compared with the nonassistance gap group, individuals in the assistance gap were more likely to have lower levels of education, have at least one chronic condition, be uninsured at baseline, and be seeking health care coverage for additional dependents. Individuals in the assistance gap had significantly lower annual incomes and higher annual premiums when compared with the nonassistance gap group and were less likely to be insured through the marketplace or other private insurance at the 1-year follow-up. Findings provide several practice and policy implications for expanding health insurance coverage, reducing costs, and improving access to care for underserved populations.

Condom deserts: geographical disparities in condom availability and their relationship with rates of sexually transmitted infections.

BACKGROUND: Identifying predictors that contribute to geographical disparities in sexually transmitted infections (STIs) is necessary. This study assesses the spatial relationship between condom availability to locations of STIs in order to better understand these geographical disparities. OBJECTIVES: We conducted a condom availability audit among potential condom-selling establishments. New gonorrhoea and chlamydia cases in 2011 (n=6034) and HIV infection cases from 2006 to 2011 (n=565) were collected by census tract in St Louis, Missouri. 829 potential condom-selling establishments participated in the condom availability audit in St Louis City; 242 of which sold condoms. RESULTS: A negative linear relationship exists between condom vendors and cases of gonorrhoea and chlamydia, after adjusting for concentrated disadvantage and free condom locations. Higher concentrated disadvantage, higher proportions of convenience vendors and free locations were associated with higher rates of HIV. CONCLUSIONS: This study was conducted to provide evidence that lack of condom availability is associated with STI rates, and likely is an integral component to influencing the subjective norms surrounding condom use and STI rates. Condom distribution interventions may be addressing availability needs and social norms, yet are more likely to be effective when placed in locations with the highest STI rates.

Geographic Variation in Condom Availability and Accessibility.

Identifying predictors that contribute to geographic disparities in sexually transmitted infections (STIs) is necessary in order to reduce disparities. This study assesses the spatial relationship condom availability and accessibility in order to better identify determinants of geographic disparities in STIs. We conducted a telephone-based audit among potential-condom selling establishments. Descriptive analyses were conducted to detect differences in condom-selling characteristics by stores and by store type. Geocoding, mapping, and spatial analysis were conducted to measure the availability of condoms. A total of 850 potential condom-selling establishments participated in the condom availability and accessibility audit in St. Louis city; 29 % sold condoms. There were several significant geographic clusters of stores identified across the study area. The first consisted of fewer convenience stores and gas stations that sold condoms in the northern section of the city, whereas condoms were less likely to be sold in non-convenience store settings in the southwestern and central parts of the city. Additionally, locations that distributed free condoms clustered significantly in city center. However, there was a dearth of businesses that were neither convenience stores nor gas stations in the northern region of the city, which also had the highest concentration of condoms sold. This initial study was conducted to provide evidence that condom availability and accessibility differ by geographic region, and likely are a determinant of social norms surrounding condom use and ultimately impact STI rates.

Show Me My Health Plans: a study protocol of a randomized trial testing a decision support tool for the federal health insurance marketplace in Missouri.

BACKGROUND: The implementation of the ACA has improved access to quality health insurance, a necessary first step to improving health outcomes. However, access must be supplemented by education to help individuals make informed choices for plans that meet their individual financial and health needs. METHODS/DESIGN: Drawing on a model of information processing and on prior research, we developed a health insurance decision support tool called Show Me My Health Plans. Developed with extensive stakeholder input, the current tool (1) simplifies information through plain language and graphics in an educational component; (2) assesses and reviews knowledge interactively to ensure comprehension of key material; (3) incorporates individual and/or family health status to personalize out-of-pocket cost estimates; (4) assesses preferences for plan features; and (5) helps individuals weigh information appropriate to their interests and needs through a summary page with "good fit" plans generated from a tailored algorithm. The current study will evaluate whether the online decision support tool improves health insurance decisions compared to a usual care condition (the healthcare.gov marketplace website). The trial will include 362 individuals (181 in each group) from rural, suburban, and urban settings within a 90 mile radius around St. Louis. Eligibility criteria includes English-speaking individuals 18-64 years old who are eligible for the ACA marketplace plans. They will be computer randomized to view the intervention or usual care condition. DISCUSSION: Presenting individuals with options that they can understand tailored to their needs and preferences could help improve decision quality. By helping individuals narrow down the complexity of health insurance plan options, decision support tools such as this one could prepare individuals to better navigate enrollment in a plan that meets their individual needs. The randomized trial was registered in clinicaltrials.gov (NCT02522624) on August 6, 2015.

Childhood lead exposure and sexually transmitted infections: New evidence.

INTRODUCTION: The adverse health effects of lead exposure in children are well documented and include intellectual and behavioral maladies. Childhood lead exposure has also been linked to impulsive behaviors, which, in turn, are associated with a host of negative health outcomes including an increased risk for sexually transmitted infections (STI). The purpose of this study was to assess the association of lead exposure with STI rates across census tracts in St. Louis City, Missouri. METHODS: Incident cases of gonorrhea and chlamydia (GC) during 2011 were identified from the Missouri Department of Health and Senior Services and aggregated by census tract. We also geocoded the home address of 59,645 children >72 months in age who had blood lead level tests performed in St. Louis City from 1996 to 2007. Traditional regression and Bayesian spatial models were used to determine the relationship between GC and lead exposure while accounting for confounders (condom and alcohol availability, crime, and an index of concentrated disadvantage). RESULTS: Incident GC rates were found to cluster across census tracts (Moran's I=0.13, p=0.006). After accounting for confounders and their spatial dependence, a linear relationship existed between lead exposure and GC incidence across census tracts, with higher GC rates occurring in the northern part of St. Louis City CONCLUSIONS: At the census-tract level, higher lead exposure is associated with higher STI rates. Visualizing these patterns through maps may help deliver targeted interventions to reduce geographic disparities in GC rates.

Depression severity is associated with increased risk behaviors and decreased CD4 cell counts.

Depression is a common comorbidity among HIV-infected individuals. We studied the relationship between depressive symptoms, risk behaviors (risky-sexual behavior, tobacco, alcohol, and illicit drug use) and HIV outcomes. This cross-sectional study conducted in 2009 at the Washington University HIV Clinic included screening for depression with patient health questionnaire, survey of sexual behavior, illicit drug, alcohol, and tobacco use within 30 days. Sociodemographics, plasma HIV RNA levels, CD4 cell counts, and sexually transmitted disease test results were obtained from medical records. Multivariate logistic and linear regression models were used to assess the association between depressive symptoms severity and risk behaviors, HIV outcomes and combination antiretroviral therapy (cART) adherence. A total of 624 persons completed the assessment of whom 432 (69%) were male and 426 (68%) African-American. The median CD4 cell count was 410 cells/mm(3) and 479 persons (77%) were on cART of whom 112 (23%) had HIV RNA level > 400 copies/mL. Overall, 96 (15%) had symptoms of major depressive disorder. Depressive symptom severity was associated with increased likelihood of high-risk drinking (odds ratio [OR], 2.4; 95% confidence interval [CI], 1.1-5.1), current tobacco use (OR, 1.8; 95% CI, 1.1-2.9), illicit drug use (OR, 1.7; 95% CI, 1.0-2.8), and risky-sexual behavior (OR, 1.5; 95% CI, 0.8-2.7). Suboptimal cART adherence (visual analog scale < 95%) was also associated with depressive symptoms severity (p < 0.05). After adjustment for age, sex, race, receipt of cART, and cART adherence, depressive symptoms severity was independently associated with lower CD4 cell count (p < 0.05) but not with higher HIV RNA level (p = 0.39). Depression adversely affects HIV-infected individuals, requiring greater effort at utilizing multidisciplinary interventions.