Food is Medicine for HIV: Improved health and hospitalizations in the Changing Health through Food Support (CHEFS-HIV) pragmatic randomized trial.

BACKGROUND: Policy support for "Food is Medicine"-medically tailored meals or groceries to improve health-is rapidly growing. No randomized trials have heretofore investigated the benefits of medically tailored food programs for people living with HIV (PLHIV). METHODS: The CHEFS-HIV pragmatic randomized trial included PLHIV who were clients of Project Open Hand (POH), a San Francisco-based nonprofit food organization. The intervention arm (n = 93) received comprehensive medically tailored meals, groceries, and nutritional education. Control participants (n = 98) received less intensive (POH "standard of care") food services. Health, nutrition, and behavioral outcomes were assessed at baseline and 6 months later. Primary outcomes measured were viral non-suppression and health related quality of life. Mixed models estimated treatment effects as differences-in-differences between arms. RESULTS: The intervention arm had lower odds of hospitalization (odds ratio [OR] = 0.11), food insecurity (OR = 0.23), depressive symptoms (OR = 0.32), antiretroviral therapy adherence <90% (OR = 0.18), and unprotected sex (OR = 0.18), and less fatty food consumption (ß= -0.170 servings/day) over 6 months, compared to the control arm. There was no difference between study arms in viral non-suppression and health-related quality of life over 6 months. CONCLUSIONS: A "Food-is-Medicine" intervention reduced hospitalizations and improved mental and physical health among PLHIV, despite no impact on viral suppression. CLINICAL TRIALS REGISTRATION: NCT03191253.

Complementing the United States Household Food Security Survey Module with Items Reflecting Social Unacceptability.

BACKGROUND: Social unacceptability of food access is part of the lived experience of food insecurity but is not assessed as part of the United States Household Food Security Survey Module (HFSSM). OBJECTIVES: The objectives were as follows: 1) to determine the psychometric properties of 2 additional items on social unacceptability in relation to the HFSSM items and 2) to test whether these 2 items provided added predictive accuracy to that of the HFSSM items for mental health outcomes. METHODS: Cross-sectional data used were from the Intersection of Material-Need Insecurities and HIV and Cardiovascular Health substudy of the Multicenter AIDS Cohort Study/Women's Interagency HIV Study Combined Cohort Study. Data on the 10-item HFSSM and 2 new items reflecting social unacceptability were collected between Fall 2020 and Fall 2021 from 1342 participants from 10 United States cities. The 2 social unacceptability items were examined psychometrically in relation to the HFSSM-10 items using models from item response theory. Linear and logistic regression was used to examine prediction of mental health measured by the 20-item Center for Epidemiologic Studies Depression scale and the 10-item Perceived Stress Scale. RESULTS: The social unacceptability items were affirmed throughout the range of severity of food insecurity but with increasing frequency at higher severity of food insecurity. From item response theory models, the subconstructs reflected in the HFSSM-10 and the subconstruct of social unacceptability were distinct, not falling into one dimension. Regression models confirmed that social unacceptability was distinct from the subconstructs reflected in the HFSSM-10. The social unacceptability items as a separate scale explained more (∼1%) variation in mental health than when combined with the HFSSM-10 items in a single scale, and the social unacceptability subconstruct explained more (∼1%) variation in mental health not explained by the HFSSM-10. CONCLUSIONS: Two social unacceptability items used as a separate scale along with the HFSSM-10 predicted mental health more accurately than did the HFSSM-10 alone.

Intersectional Stigma, Fear of Negative Evaluation, Depression, and ART Adherence Among Women Living with HIV Who Engage in Substance Use: A Latent Class Serial Mediation Analysis.

Women Living with HIV (WLHIV) who use substances face stigma related to HIV and substance use (SU). The relationship between the intersection of these stigmas and adherence to antiretroviral therapy (ART), as well as the underlying mechanisms, remains poorly understood. This study aimed to examine the association between intersectional HIV and SU stigma and ART adherence, while also exploring the potential role of depression and fear of negative evaluation (FNE) by other people in explaining this association. We analyzed data from 409 WLHIV collected between April 2016 and April 2017, Using Multidimensional Latent Class Item Response Theory analysis. We identified five subgroups (i.e., latent classes [C]) of WLHIV with different combinations of experienced SU and HIV stigma levels: (C1) low HIV and SU stigma; (C2) moderate SU stigma; (C3) higher HIV and lower SU stigma; (C4) moderate HIV and high SU stigma; and (C5) high HIV and moderate SU stigma. Medication adherence differed significantly among these classes. Women in the class with moderate HIV and high SU stigma had lower adherence than other classes. A serial mediation analysis suggested that FNE and depression symptoms are mechanisms that contribute to explaining the differences in ART adherence among WLHIV who experience different combinations of intersectional HIV and SU stigma. We suggest that FNE is a key intervention target to attenuate the effect of intersectional stigma on depression symptoms and ART adherence, and ultimately improve health outcomes among WLHIV.

Barriers to accessing care for cardiometabolic disorders in Malawi: partners as a source of resilience for people living with HIV.

BACKGROUND: People living with HIV (PLWH) are at increased risk of cardiometabolic disorders (CMD). Adequate access to care for both HIV and CMD is crucial to improving health outcomes; however, there is limited research that have examined couples' experiences accessing such care in resource-constrained settings. We aimed to identify barriers to accessing CMD care among PLWH in Malawi and the role of partners in mitigating these barriers. METHODS: We conducted a qualitative investigation of barriers to CMD care among 25 couples in Malawi. Couples were eligible if at least one partner was living with HIV and had hypertension or diabetes (i.e., the index patient). Index patients were recruited from HIV care clinics in the Zomba district, and their partners were enrolled thereafter. Interviews were conducted separately with both partners to determine barriers to CMD care access and how partners were involved in care. RESULTS: Participants framed their experiences with CMD care by making comparisons to HIV treatment, which was free and consistently available. The main barriers to accessing CMD care included shortage of medications, cost of tests and treatments, high cost of transportation to health facilities, lengthy wait times at health facilities, faulty or unavailable medical equipment and supplies, inadequate monitoring of patients' health conditions, some cultural beliefs about causes of illness, use of herbal therapies as an alternative to prescribed medicine, and inadequate knowledge about CMD treatments. Partners provided support through decision-making on accessing medical care, assisting partners in navigating the healthcare system, and providing financial assistance with transportation and treatment expenses. Partners also helped manage care for CMD, including communicating health information to their partners, providing appointment reminders, supporting medication adherence, and supporting recommended lifestyle behaviors. CONCLUSIONS: Couples identified many barriers to CMD care access, which were perceived as greater challenges than HIV care. Partners provided critical forms of support in navigating these barriers. With the rise of CMD among PLWH, improving access to CMD care should be prioritized, using lessons learned from HIV and integrated care approaches. Partner involvement in CMD care may help mitigate most barriers to CMD care.

The mitigated carbon emissions of transitioning to virtual medical school and residency interviews: A survey-based study.

PURPOSE: Prior to COVID, thousands of medical school and residency applicants traversed their countries for in-person interviews each year. However, data on the greenhouse gas emissions from in-person interviews is limited. This study estimated greenhouse gas emissions associated with in-person medical school and residency interviews and explored applicant interview structure preferences. METHODS: From March to June 2022, we developed and distributed a nine-question, website-based survey to collect information on applicant virtual interview schedule, demographics and preference for future interview format. We calculated theoretical emissions for all interviews requiring air travel and performed a content analysis of interview preference explanations. RESULTS: We received responses from 258 first-year and 253 fourth-year medical students at 26 allopathic US medical schools who interviewed virtually in 2020-2021 and 2021-2022, respectively. Residency applicants participating in the study were interviewed at a mean of 15.3 programs (SD 5.4) and had mean theoretical emissions of 4.31 tons CO2 eq. Medical school applicants participating in the study were interviewed at a mean of 6.9 programs and had mean theoretical emissions of 2.19 tons CO2 eq. Ninety percent of medical school applicants and 91% of residency applicants participating in the study expressed a preference for hybrid or virtual interviews going forward. CONCLUSION: In-person medical training interviews have significant greenhouse gas emissions. Virtual and hybrid alternatives have a high degree of acceptability among applicants.

Identifying Paucisymptomatic or Asymptomatic and Unrecognized Ebola Virus Disease Among Close Contacts Based on Exposure Risk Assessments and Screening Algorithms.

BACKGROUND: There is limited evidence to evaluate screening algorithms with rapid antigen testing and exposure assessments as identification strategies for paucisymptomatic or asymptomatic Ebola virus (EBOV) infection and unrecognized EBOV disease (EVD). METHODS: We used serostatus and self-reported postexposure symptoms from a cohort study to classify contact-participants as having no infection, paucisymptomatic or asymptomatic infection, or unrecognized EVD. Exposure risk was categorized as low, intermediate, or high. We created hypothetical scenarios to evaluate the World Health Organization (WHO) case definition with or without rapid diagnostic testing (RDT) or exposure assessments. RESULTS: This analysis included 990 EVD survivors and 1909 contacts, of whom 115 (6%) had paucisymptomatic or asymptomatic EBOV infection, 107 (6%) had unrecognized EVD, and 1687 (88%) were uninfected. High-risk exposures were drivers of unrecognized EVD (adjusted odds ratio, 3.5 [95% confidence interval, 2.4-4.9]). To identify contacts with unrecognized EVD who test negative by the WHO case definition, the sensitivity was 96% with RDT (95% confidence interval, 91%-99%), 87% with high-risk exposure (82%-92%), and 97% with intermediate- to high-risk exposures (93%-99%). The proportion of false-positives was 2% with RDT and 53%-93% with intermediate- and/or high-risk exposures. CONCLUSION: We demonstrated the utility and trade-offs of sequential screening algorithms with RDT or exposure risk assessments as identification strategies for contacts with unrecognized EVD.

Links between Household-Level Income-Generating Agricultural Intervention and the Psychological Well-Being of Adolescent Girls in Human Immunodeficiency Virus-Affected Households in Southwestern Kenya: A Qualitative Inquiry.

BACKGROUND: Adolescent girls may experience poor psychological well-being, such as social isolation, shame, anxiety, hopelessness, and despair linked to food insecurity. OBJECTIVES: This study aimed to investigate the experiences with and perceived effects of a household-level income-generating agricultural intervention on the psychological well-being of adolescent girls in human immunodeficiency virus (HIV)-affected households in southwestern Kenya. METHODS: We conducted 62 in-depth interviews with HIV-affected adolescent girls and caregiver dyads in Adolescent Shamba Maisha (NCT03741634), a sub-study of adolescent girls and caregivers with a household member participating in Shamba Maisha (NCT01548599), a multisectoral agricultural and finance intervention trial aimed to improve food security and HIV health indicators. Participants were purposively sampled to ensure diversity in terms of age and location. Data were audiotaped, transcribed, translated, and uploaded into Dedoose (Sociocultural Research Consultants, LLC) software for management. Data were analyzed thematically based on reports from Dedoose. RESULTS: We found evidence that a household-level structural intervention aimed at increasing food and financial security among persons living with HIV can contribute to better psychological well-being among adolescent girls residing in these households. The intervention also affected: 1) reduction of social isolation, 2) reduction of shame and stigma, 3) increased attendance and concentration in school, 4) improved caregiver mental health, and 5) reduced parental aggression and improved household communication. These associations were reported more commonly among those in the intervention arm than the control arm. CONCLUSIONS: This study extends existing research by demonstrating how multisectoral structural interventions delivered at a household level can improve the psychological well-being of adolescents. We recommend that future research test livelihood interventions designed specifically for adolescent girls that integrate food-security interventions with other elements to address the social and psychological consequences of food insecurity holistically. This trial was registered at clinicaltrials.gov as NCT03741634.

Drought, HIV Testing, and HIV Transmission Risk Behaviors: A Population-Based Study in 10 High HIV Prevalence Countries in Sub-Saharan Africa.

Droughts are associated with poor health outcomes and disruption of public health programming. Data on the association between drought and HIV testing and transmission risk behaviors are limited. We combined data from Demographic and Health Surveys from 10 high HIV prevalence sub-Saharan African countries with a high-resolution measure of drought. We estimated the association between drought and recent HIV testing, report of condomless sex, and number of sexual partners in the last year. Respondents exposed to drought were less likely to have an HIV test and more likely to have condomless sex, although effect sizes were small. We found evidence for effect modification by sex and age for the association between drought and HIV testing, such that the negative association between drought and HIV testing was strongest among men (marginal risk ratio [mRR] 0.92, 95% CI 0.89-0.95) and adolescents (mRR 0.90, 95% CI 0.86-0.93). Drought may hinder HIV testing programs in countries with high HIV prevalence.

Financial and Food Insecurity are Primary Challenges to Breastfeeding for Women Living with HIV in Western Kenya: A Longitudinal Qualitative Investigation.

Exclusive breastfeeding for the first 6 months and continued breastfeeding for 24 months or longer is recommended for all mothers world-wide, including women living with HIV (WLWH). Given evidence of suboptimal infant feeding and the need to understand context specific barriers, we explored experiences of perinatal WLWH in Kisumu, Kenya. We applied a longitudinal qualitative approach (4 in-depth interviews) with 30 women from pregnancy to 14-18 months postpartum. Cross-sectional profiling led to a narrative description of infant feeding across time. The majority of women breastfed exclusively for 6 months and weaned by 18 months. Severe financial and food insecurity were primary challenges as women worked through when/how to breastfeed or stop breastfeeding in the setting of multiple competing priorities/pressures across time. Financial and food support and increased support for breastfeeding beyond 18 months have the potential to reduce women's stress and uncertainty associated with infant feeding as well as optimize infant health and nutrition in this setting.

RESUMEN: Se recomienda la lactancia materna exclusiva durante los primeros 6 meses y la continuación de la lactancia durante 24 meses o más para todas las madres en todo el mundo, incluidas las mujeres que viven con el VIH (WLWH). Debido a la evidencia de alimentación infantil subóptima y la necesidad de comprender las barreras específicas del contexto, exploramos las experiencias de WLWH perinatal en Kisumu, Kenia. Aplicamos un enfoque cualitativo longitudinal (4 entrevistas en profundidad) con 30 mujeres desde el embarazo hasta los 14-18 meses posparto. El perfil transversal resultó en una descripción narrativa de la alimentación infantil a través del tiempo. La mayoría de las mujeres amamantaron exclusivamente durante 6 meses y dejó de amamantar a los 18 meses. La grave inseguridad financiera y alimentaria fueron los principales desafíos cuando las mujeres analizaban cuándo y cómo amamantar o dejar de amamantar en el contexto de múltiples prioridades y presiones en competencia a través del tiempo. El apoyo financiero y alimentario y un mayor apoyo para la lactancia más allá de los 18 meses tienen el potencial de reducir el estrés y la incertidumbre de las mujeres asociados con la alimentación infantil, así como optimizar la salud y la nutrición infantil en este entorno.

Relationship Power, Antiretroviral Adherence, and Physical and Mental Health Among Women Living with HIV in Rural Kenya.

Little is known about the association of gender-based power imbalances and health and health behaviors among women with HIV (WWH). We examined cross-sectional baseline data among WWH in a cluster-randomized control trial (NCT02815579) in rural Kenya. We assessed associations between the Sexual Relationship Power Scale (SRPS) and ART adherence, physical and mental health, adjusting for sociodemographic and social factors. SRPS consists of two subscales: relationship control (RC) and decision-making dominance. Women in the highest and middle tertiles for RC had a 7.49 point and 8.88 point greater Medical Outcomes Study-HIV mental health score, and a 0.27 and 0.29 lower odds of depression, respectively, compared to women in the lowest tertile. We did not find associations between SPRS or its subscales and ART adherence. Low sexual relationship power, specifically low RC, may be associated with poor mental health among WWH. Intervention studies aimed to improve RC among WWH should be studied to determine their effect on improving mental health.

RESUMEN: Poco se sabe acerca de su asociación con los desequilibrios de poder basados en el género y los comportamientos de salud y salud entre las mujeres con Virus de Inmunodeficiencia Humana (VIH). Examinamos los datos de referencia transversales entre mujeres con VIH en un ensayo de control aleatorizado por grupos (NCT02815579) en las zonas rurales de Kenia. Evaluamos las asociaciones entre la Escala de Poder de Relación Sexual y la adherencia a la Terapia Antirretroviral (TAR), la salud física y mental, ajustando por factores sociodemográficos y sociales. La Escala de Poder de Relación Sexual consiste de dos subescalas: control de relaciones y dominio en la toma de decisiones. Las mujeres en los terciles más alto y mediano para control de relaciones tenían una puntuación de salud mental de 7.49 puntos y 8.88 puntos mayor en el Medical Outcomes Study HIV Health Survey (MOS)-HIV, y una puntuación de salud mental de 0.27 y 0.29 menores probabilidades de depresión, respectivamente, en comparación con las mujeres en el tercil más bajo. El bajo poder de relación sexual, específicamente el control de relaciones bajo, puede estar asociado con una salud mental deficiente entre las mujeres con VIH. Se deben estudiar estudios de intervención destinados a mejorar el control de relaciones entre mujeres con VIH para determinar su efecto en mejorar la salud mental.

The Impact of Land Tenure Security on a Livelihood Intervention for People Living with HIV in Western Kenya.

Few studies have explored land access, a structural driver of health, and women's participation in livelihood interventions to improve food security and HIV outcomes. This qualitative study, embedded within Shamba Maisha (NCT02815579)-a randomized controlled trial (RCT) examining the impact of a multisectoral intervention among farmers living with HIV in western Kenya-sought to explore the influence of perceived access to and control of land on agricultural productivity, investments, and benefits. Thirty in-depth interviews (IDIs) were conducted with purposively sampled men and women, 3 to 6 months after receiving intervention inputs; data were deductively and inductively coded and analyzed. Farming practices and participation in Shamba Maisha were dependent on land tenure and participants' perceived strength of claim over their land, with participants who perceived themselves to be land insecure less likely to make long-term agricultural investments. Land tenure was influenced by a number of factors and posed unique challenges for women which negatively impacted uptake and success in the intervention. Data underscore the importance of secure land tenure for the success of similar interventions, especially for women; future interventions should integrate land security programming for improved outcomes for all.

Food Insecurity and Transmission Risks Among People with HIV Who Use Substances.

Food insecurity (FI) impacts people with HIV (PWH) and those who use substances (i.e. drugs and alcohol). We evaluated the longitudinal association between FI and HIV transmission risks (unprotected sexual contacts and shared needles/syringes). Among 351 PWH who use substances in Russia, 51.6% reported FI and 37.0% past month injection drug use. The mean number of unprotected sexual contacts in the past 90 days was 13.4 (SD 30.1); 9.7% reported sharing needles/syringes in the past month. We did not find a significant association between mild/moderate FI (adjusted IRR = 0.87, 95% CI 0.47, 1.61) or severe FI (aIRR = 0.84, 95% CI 0.46, 1.54; global p = 0.85) and unprotected sexual contacts. We observed a significant association between severe FI and sharing needles/syringes in the past month (adjusted OR = 3.27, 95% CI 1.45, 7.39; p = 0.004), but not between mild/moderate FI and sharing needles/syringes in the past month (aOR = 1.40,95% CI 0.58, 3.38; p = 0.45). These findings suggest that severe FI could be a potential target for interventions to lower HIV transmission.

RESUMEN: La inseguridad alimentaria (IF) afecta a las personas que viven con VIH (PVV y a personas con abuso desustancias (.ej. drogas y alcohol). Evaluamos la asociación longitudinal entre la IF y los riesgos de transmisión del VIH (relaciones sexuales sin protección y agujas/jeringas compartidas). Entre 351 PVVcon abuso de sustancias en Rusia, el 51,6% reportó FI y el 37,0% consumió drogas intravenosas en el último mes. El promedio de contactos sexuales sin protección en los últimos 90 días fue de 13,4 (DE 30,1); el 9,7% informó haber compartido agujas/jeringas en el último mes. No encontramos una asociación significativa entre IF leve/moderada (IRR ajustada = 0,87, IC 95% = 0,47, 1,61) o IF grave (IRRa = 0,84, IC 95% = 0,46, 1,54; p global = 0,85) y relaciones sexuales sin protección. Observamos una asociación significativa entre IF grave y compartir agujas/jeringas en el último mes (OR ajustado = 3,27, IC 95% = 1,45, 7,39; p = 0,004), pero no entre IF leve/moderada y compartir agujas/jeringas en el último mes (ORa = 1,40, IC 95% = 0,58, 3,38; p = 0,45). Estos hallazgos sugieren que la IF grave podría ser un enfoque para intervenciones que buscan reducir la transmisión del VIH.

Longitudinal Relationship Between Food Insecurity, Engagement in Care, and ART Adherence Among US Women Living with HIV.

Food insecurity disproportionately affects people with HIV and women in the United States (US). More evidence is needed to understand the interplay between levels of food insecurity and levels of antiretroviral therapy (ART) adherence over time, as well as how food insecurity relates to engagement in HIV care. We used random effects models with longitudinal data from the US Women's Interagency HIV Study to estimate the (1) adjusted associations of current and 6-month lagged food security with ART adherence categories (n = 1646), and (2) adjusted associations of food security with engagement-in-care (n = 1733). Very low food security was associated with a higher relative risk of ART non-adherence at prior and current visits compared with food security, and this association increased across non-adherence categories. Very low food security was associated with lower odds of receiving HIV care and higher odds of a missed visit. Food insecurity among US women with HIV is associated with poorer engagement in care and degree of ART non-adherence over time.

Food insecurity and binge-eating disorder in early adolescence.

OBJECTIVE: Food insecurity is defined as lack of consistent access to adequate food for healthy living. The objective of this study was to determine the associations between food insecurity and binge-eating disorder in a national cohort of 9- to 14-year-old children. METHOD: We analyzed prospective cohort data from the Adolescent Brain Cognitive Development (ABCD) Study (N = 10,035, 2016-2020). Logistic regression analyses estimated the associations between food insecurity at baseline, year 1, or year 2 (exposure) and binge eating, subclinical binge-eating disorder (Other Specified Feeding and Eating Disorder-Binge-Eating Disorder [OSFED-BED]), and binge-eating disorder (BED) (outcome) based on the Kiddie Schedule for Affective Disorders and Schizophrenia (KSADS-5) at 2-year follow-up. RESULTS: The prevalence of food insecurity in the study was 15.8%. At 2-year follow-up, 1.71% of the sample received a diagnosis of BED or OSFED-BED, while 6.62% reported binge eating. Food insecurity was associated with 1.67 higher odds of BED or OSFED-BED (95% CI 1.04-2.69) and 1.31 higher odds of binge-eating symptoms (95% CI 1.01-1.71). DISCUSSION: Food insecurity in early adolescence is associated with higher odds of developing future binge-eating and BED or OSFED-BED. Clinicians may consider assessing for binge eating in adolescents with food insecurity and provide support in accessing appropriate food resources. PUBLIC SIGNIFICANCE: Prior research has shown that food insecurity is associated with disordered eating behaviors, including binge eating in adulthood. This study explored whether food insecurity in early adolescence increases risk for developing binge-eating disorder (BED). Targeted screening for BED in adolescents experiencing FI, and vice versa, may be warranted.

Do precipitation anomalies influence short-term mobility in sub-saharan Africa? An observational study from 23 countries.

BACKGROUND: Precipitation anomalies are associated with a number of poor health outcomes. One potential consequence of precipitation extremes is human geographic mobility. We evaluated the associations between precipitation anomalies (droughts and heavy rains) and short-term mobility in 23 sub-Saharan African countries by linking satellite data on precipitation to cross-sectional representative surveys. METHODS: Using data from 23 Demographic and Health Surveys from 2011 to 2017, we estimated the associations between deviations in long-term rainfall trends and short-term mobility among 294,539 women and 136,415 men over 15 years of age. We fit multivariable logistic regression models to assess potential non-linear relationships between rainfall deviations and short-term mobility, adjusting for survey month and socio-demographic covariates, and stratified by participant gender. Furthermore, we assessed whether these associations differed by marital status. RESULTS: Rainfall deviations were associated with short-term mobility among women, but not men. The relationship between rainfall deviations and mobility among women was U-shaped, such that women had increased marginal probabilities of mobility in instances of both lower and heavier precipitation. Differences between married and unmarried women were also revealed: among married women, we found positive associations between both rainfall deviation extremes (drought and heavy rains) and mobility; however, among unmarried women, there was only a positive association for heavy rains. CONCLUSION: Precipitation anomalies were associated with short-term mobility among women, which may be in turn associated with poor health outcomes. More research with longitudinal data is needed to elaborate the associations between weather shocks, mobility, and downstream health impacts.

Extreme weather events and HIV: development of a conceptual framework through qualitative interviews with people with HIV impacted by the California wildfires and their clinicians.

BACKGROUND: People with HIV (PWH) are disproportionately vulnerable to the impacts of wildfires, given the need for frequent access to healthcare systems, higher burden of comorbidities, higher food insecurity, mental and behavioral health challenges, and challenges of living with HIV in a rural area. In this study, we aim to better understand the pathways through which wildfires impact health outcomes among PWH. METHODS: From October 2021 through February 2022, we conducted individual semi-structured qualitative interviews with PWH impacted by the Northern California wildfires and clinicians of PWH who were impacted by wildfires. The study aims were to explore the influence of wildfires on the health of PWH and to discuss measures at the individual, clinic, and system levels that helped to mitigate these impacts. RESULTS: We interviewed 15 PWH and 7 clinicians. While some PWH felt that surviving the HIV epidemic added to their resilience against wildfires, many felt that the wildfires compounded the HIV-related traumas that they have experienced. Participants outlined five main routes by which wildfires negatively impacted their health: (1) access to healthcare (medications, clinics, clinic staff), (2) mental health (trauma; anxiety, depression, or stress; sleep disturbances; coping strategies), (3) physical health (cardiopulmonary, other co-morbidities), (4) social/economic impacts (housing, finances, community), and (5) nutrition and exercise. The recommendations for future wildfire preparedness were at the (1) individual-level (what to have during evacuation), (2) pharmacy-level (procedural, staffing), and (3) clinic- or county-level (funds and vouchers; case management; mental health services; emergency response planning; other services such as telehealth, home visits, home laboratory testing). CONCLUSIONS: Based on our data and prior research, we devised a conceptual framework that acknowledges the impact of wildfires at the community-, household-, and individual-level with implications for physical and mental health outcomes among PWH. These findings and framework can help in developing future interventions, programs, and policies to mitigate the cumulative impacts of extreme weather events on the health of PWH, particularly among individuals living in rural areas. Further studies are needed to examine health system strengthening strategies, innovative methods to improve access to healthcare, and community resilience through disaster preparedness. TRIAL REGISTRATION: N/A.

Menopause Is Associated With Immune Activation in Women With HIV.

BACKGROUND: Persistent immune activation due to gut barrier dysfunction is a suspected cause of morbidity in HIV, but the impact of menopause on this pathway is unknown. METHODS: In 350 women with HIV from the Women's Interagency HIV Study, plasma biomarkers of gut barrier dysfunction (intestinal fatty acid binding protein; IFAB), innate immune activation (soluble CD14 and CD163; sCD14, sCD163), and systemic inflammation (interleukin-6 and tumor necrosis factor receptor 1; IL-6, TNFR1) were measured at 674 person-visits spanning ≤2 years. RESULTS: Menopause (post- vs premenopausal status) was associated with higher plasma sCD14 and sCD163 in linear mixed-effects regression adjusting for age and other covariates (ß = 161.89 ng/mL; 95% confidence interval [CI], 18.37-305.41 and 65.48 ng/mL, 95% CI, 6.64-124.33, respectively); but not with plasma IFAB, IL-6, or TNFR1. In piece-wise linear mixed-effects regression of biomarkers on years before/after the final menstrual period, sCD14 increased during the menopausal transition by 250.71 ng/mL per year (95% CI, 16.63-484.79; P = .04), but not in premenopausal or postmenopausal periods. CONCLUSIONS: In women with HIV, menopause may increase innate immune activation, but data did not support an influence on the gut barrier or inflammation. Clinical implications of immune activation during menopausal transition warrant further investigation.

Exploring the Association Between Social Support and Hazardous Alcohol Use Among Persons Living with HIV in South Western Uganda.

Hazardous alcohol use and psychological distress are common among persons living with HIV (PLWH). In Uganda, HIV prevalence is 6.2% with average pure alcohol consumption per capita of 9.8 L. Social support may mitigate hazardous alcohol use. In a cohort of 443 PLWH, we measured social support using the Duke-UNC functional social support scale and self-reported alcohol consumption using the Alcohol Use Disorders Identification Test-Consumption (AUDIT-C), augmented by phosphatidylethanol (PEth). We examined the association between low social support and hazardous alcohol use using multiple logistic regression models. 30% had low social support and 44% had hazardous alcohol use (AUDIT-C ≥ 3 for women and ≥ 4 for men and/or PEth ≥ 50 ng/mL). We did not detect an association between low social support and hazardous alcohol use. Social support may play no role or a minimal role in preventing PLWH from hazardous alcohol use.

Water Insecurity is Associated with Lack of Viral Suppression and Greater Odds of AIDS-Defining Illnesses Among Adults with HIV in Western Kenya.

Reliable access to safe and acceptable water in sufficient quantities (i.e., water security) is important for medication adherence and limiting pathogen exposure, yet prior studies have only considered the role of food security as a social determinant of HIV-related health. Therefore, the objective of this analysis was to assess the relationships between household water insecurity and HIV-related outcomes among adults living with HIV in western Kenya (N = 716). We conducted a cross-sectional analysis of baseline data from Shamba Maisha (NCT02815579), a cluster randomized controlled trial of a multisectoral agricultural and asset loan intervention. Baseline data were collected from June 2016 to December 2017. We assessed associations between water insecurity and HIV-related outcomes, adjusting for clinical and behavioral confounders, including food insecurity. Each five-unit higher household water insecurity score (range: 0-51) was associated with 1.21 higher odds of having a viral load ≥ 1000 copies/mL (95% CI 1.07, 1.36) and 1.26 higher odds of AIDS-defining illness (95% CI 1.11, 1.42). Household water insecurity was not associated with CD4 cell count (B: 0.27; 95% CI -3.59, 13.05). HIV treatment and support programs should consider assessing and addressing water insecurity in addition to food insecurity to optimize HIV outcomes.

RESUMEN: El acceso seguro al agua potable en cantidades suficientes (es decir, seguridad hídrica) es importante para la adherencia a la medicación y para limitar la exposición a patógenos; sin embargo, estudios anteriores solo han considerado el papel de la seguridad alimentaria como un determinante social de salud relacionado con el VIH. Por lo tanto, el objetivo de este análisis fue evaluar las relaciones entre la inseguridad hídrica en hogares y los resultados relacionados con el VIH en adultos que viven con VIH en el oeste de Kenia (N = 716). Realizamos un análisis transversal de los datos basales de la iniciativa Shamba Maisha (NCT02815579), un ensayo controlado aleatorio por conglomerados de una intervención multisectorial de créditos para insumos agrícolas. Los datos basales se recopilaron de junio de 2016 a diciembre de 2017. Evaluamos las asociaciones entre la inseguridad hídrica y resultados relacionados con el VIH, ajustando por factores de confusión clínicos y conductuales, incluyendo inseguridad alimentaria. Cada cinco unidades superiores de puntajes de inseguridad hídrica doméstica (rango: 0-51) fue asociado con 1.21 mayores probabilidades de tener una carga viral más alta ≥ 1000 copias / ml (CI 95%: 1,07-1,36) y con 1.26 mayores probabilidades de factores determinantes del SIDA (CI 95%: 1,11-1,42). La inseguridad de hídrica doméstica no se asoció con el recuento de células CD4 (B: −0,27; CI 95%: -13,59-13,05). Los programas de tratamiento y de apoyo al VIH deben considerar evaluar y abordar la inseguridad hídrica además de la inseguridad alimentaria para optimizar los resultados del VIH.

Patient Health Literacy and Communication with Providers Among Women Living with HIV: A Mixed Methods Study.

In this mixed-methods study, we examine the relationship between provider communication and patient health literacy on HIV continuum of care outcomes among women living with HIV in the United States. We thematically coded qualitative data from focus groups and interviews (N = 92) and conducted mediation analyses with quantitative survey data (N = 1455) collected from Women's Interagency HIV Study participants. Four qualitative themes related to provider communication emerged: importance of respect and non-verbal cues; providers' expressions of condescension and judgement; patient health literacy; and unclear, insufficient provider communication resulting in diminished trust. Quantitative mediation analyses suggest that higher health literacy is associated with higher perceived patient-provider interaction quality, which in turn is associated with higher levels of trust in HIV providers, improved antiretroviral medication adherence, and reduced missed clinical visits. Findings indicate that enhancing provider communication and bolstering patient health literacy could have a positive impact on the HIV continuum of care.

RESUMEN: En este estudio de métodos mixtos, examinamos la relación entre la comunicación del proveedor y la alfabetización sanitaria del paciente sobre los resultados de la atención continua del VIH entre las mujeres que viven con el VIH en los Estados Unidos. Codificamos temáticamente datos cualitativos de grupos focales y entrevistas (N = 92) y realizamos análisis de mediación con datos de encuestas cuantitativas (N = 1455) recopilados de participantes del Estudio de VIH entre agencias de mujeres. Surgieron cuatro temas cualitativos relacionados con la comunicación con el proveedor: la importancia del respeto y las señales no verbales; las expresiones de condescendencia y juicio de los proveedores; alfabetización en salud del paciente; y una comunicación poco clara e insuficiente con el proveedor que da como resultado una disminución de la confianza. Los análisis de mediación cuantitativa sugieren que una mayor alfabetización en salud se asocia con una mayor calidad de interacción percibida entre el paciente y el proveedor, que a su vez se asocia con niveles más altos de confianza en los proveedores de VIH, una mejor adherencia a la medicación antirretroviral y una reducción de las visitas clínicas perdidas. Los resultados indican que mejorar la comunicación con los proveedores y reforzar la alfabetización sanitaria del paciente podría tener un impacto positivo en la atención continua del VIH.