Syndemic conditions and medication adherence in older men living with HIV who have sex with men.

For people living with HIV, lack of adherence to antiretroviral therapy (ART) is a serious problem and frequently results in HIV disease progression. Reasons for non-adherence include concomitant psychosocial health conditions - also known as syndemic conditions - such symptoms of depression or posttraumatic stress disorder (PTSD), past physical or sexual abuse, intimate partner violence (IPV), stimulant use, and binge drinking. The aim of this study was to investigate the association between syndemic conditions and medication adherence. The sample included 281 older men living with HIV who have sex with men (MSM). The study period was December 2012-July 2016. We observed the following syndemic conditions significantly decreased medication adherence: symptoms of depression (p = .008), PTSD (p = .002), and stimulant use (p < .0001). Past physical or sexual abuse, IPV, and binge drinking were not significantly associated with decreased medication adherence. The findings suggest that syndemic conditions may impact medication adherence in older MSM living with HIV.

The association of clinical conditions and serologic tests with CD4+ lymphocyte counts in HIV-infected subjects without AIDS.

Early intervention guidelines in HIV infection require knowledge of CD4+ lymphocyte count; however, CD4+ determinations require special laboratory procedures and may not be readily available in all situations. Using data from 207 HIV-seropositive homosexual men without AIDS, we evaluated the association of difference clinical conditions or serologic tests with CD4+ count. Men with conditions including seborrheic dermatitis, hairy leukoplakia, oral candidiasis and chronic diarrhea, and men with beta2-microglobulin levels greater than or equal to 4.0 mg/l had significantly lower CD4+ counts. However, the probability that a subject with such parameters had less than 200 x 10(6)/l CD4+ cells was limited (25-63%). Although the probability that a subject with such parameters had less than 500 x 10(6)/l CD4+ cells was better (76-88%), the probability that a person without these parameters had greater than or equal to 500 x 10(6)/l CD4+ cells was only 45-50%. Clinical and serologic parameters may provide important prognostic information, but cannot be used to reliably determine the level of CD4+ cells.

Long-term HIV-1 infection without immunologic progression.

OBJECTIVE: To identify and describe a subgroup of men infected with HIV for 10-15 years without immunologic progression, and to evaluate the effect of sexually transmitted diseases (STD) and recreational drug use on delayed HIV disease progression. DESIGN: Inception cohort study. SETTING: Municipal STD clinic. PARTICIPANTS: A total of 588 men with well documented dates of HIV seroconversion and 197 HIV-seronegative controls. MAIN OUTCOME MEASURES: AIDS, CD4+ count, rate of CD4+ cell loss, CD8+ count, beta 2-microglobulin, complete blood count, p24 antigen and HIV-related symptoms. RESULTS: Of 588 men, 69% had developed AIDS by 14 years after HIV seroconversion (95% confidence interval, 64-73%). Of 539 men with HIV seroconversion dates prior to 1983, 42 men (8%) were healthy long-term HIV-positives (HLP), HIV-infected > or = 10 years without AIDS and with CD4+ counts > 500 x 10(6)/l. When compared with progressors (men with HIV seroconversion prior to 1983 but with AIDS or CD4+ counts < 200 x 10(6)/l), HLP had a significantly slower rate of CD4+ decline (6 versus 85 x 10(6)/l cells/year), and less abnormal immunologic, hematologic and clinical parameters. However, when compared with HIV-uninfected controls, HLP demonstrated lower CD4+ counts and mild hematologic abnormalities. There were no consistent differences between HLP and progressors in prior exposure to recreational drugs or STD. CONCLUSION: There are individuals with long-term HIV infection who appear clinically and immunologically healthy 10-15 years after HIV seroconversion, with stable CD4+ counts. Lack of exposure to STD or recreational drugs does not appear to explain the delayed course of disease progression in HLP.

The prevalence of oral lesions in HIV-infected homosexual and bisexual men: three San Francisco epidemiological cohorts.

To establish the prevalence of HIV-related oral lesions, we performed oral examinations of members of three San Francisco epidemiological cohorts of homosexual and bisexual men over a 3-year period. Hairy leukoplakia, pseudomembranous and erythematous candidiasis, angular cheilitis, Kaposi's sarcoma, and oral ulcers were more common in HIV-infected subjects than in HIV-negative subjects. Among HIV-infected individuals, hairy leukoplakia was the most common lesion [20.4%, 95% confidence interval (CI) 17.5-23.3%] and pseudomembranous candidiasis was the next most common (5.8%, 95% CI 4.1-7.5%). Hairy leukoplakia, pseudomembranous candidiasis, angular cheilitis and Kaposi's sarcoma were significantly more common in patients with lower CD4 lymphocyte counts (P less than 0.05). The prevalence of erythematous candidiasis and Kaposi's sarcoma increased during the 3-year period. Careful oral examinations may identify infected patients and provide suggestive information concerning their immune status.

Progression to AIDS in HIV-infected homosexual and bisexual men with hairy leukoplakia and oral candidiasis.

OBJECTIVE: This study was designed to assess the significance of HIV-related oral lesions in predicting the rate of progression to AIDS. DESIGN: Cohorts were investigated prospectively, and oral examinations were performed by clinicians trained in the diagnosis of oral lesions. SETTING: We studied three existing cohorts of homosexual and bisexual men in San Francisco, California, USA. PARTICIPANTS: Of the HIV-infected men who received standardized oral examinations (n = 791), 603 were eligible for analysis of baseline examinations and 448 for analysis of follow-up examinations. MAIN OUTCOME MEASURES: We determined time from presence of oral lesion at baseline or follow-up examination, or from participant self-reported history of the lesion, to diagnosis of AIDS. RESULTS: Using proportional hazard regression and stratifying by CD4 lymphocyte count at the time of baseline oral examination, we found that the rate of development of AIDS was increased among men with hairy leukoplakia [relative hazard, 1.8; 95% confidence interval (CI), 1.2-2.7], oral candidiasis (relative hazard, 7.3; 95% CI, 3.1-17.3), and both lesions (relative hazard, 3.1; 95% CI, 1.6-6.1) compared with men with normal findings. On follow-up examination, stratifying for CD4 count, the rate of progression to AIDS was similar for those with hairy leukoplakia compared with those with oral candidiasis. The progression rate from oral candidiasis to AIDS was faster from presence on baseline examination than from presence on follow-up examination or from self-reported history of the lesion. CONCLUSION: The presence of oral candidiasis and/or hairy leukoplakia on baseline examination confers independent prognostic information and should be incorporated into HIV-staging schemes.

Time from HIV seroconversion to oral candidiasis or hairy leukoplakia among homosexual and bisexual men enrolled in three prospective cohorts.

OBJECTIVES: We evaluated time from HIV seroconversion to diagnosis of two common oral lesions associated with HIV infection and disease progression. DESIGN: Oral examinations were performed on homosexual and bisexual men enrolled in prospective cohorts. SETTING: Homosexual and bisexual men were followed in three epidemiologic cohort studies in San Francisco, California, USA. PARTICIPANTS: Data were evaluated from 80 men with well-defined dates of HIV seroconversion from 1984 through 1991. MAIN OUTCOME MEASURES: We determined the cumulative incidence of oral candidiasis and hairy leukoplakia after HIV seroconversion. RESULTS: Four per cent of men developed oral candidiasis within 1 year after HIV seroconversion, 8% within 2, 15% within 3, 18% within 4, and 26% within 5 years. Nine per cent developed hairy leukoplakia within 1 year, 16% within 2, 25% within 3, 35% within 4, and 42% within 5 years. The median CD4+ count was 391 x 10(6)/l when oral candidiasis was first reported and 468 x 10(6)/l when hairy leukoplakia was first reported. CONCLUSIONS: Oral candidiasis or hairy leukoplakia appeared in a significant proportion of HIV-infected homosexual and bisexual men. These lesions occurred relatively soon after HIV seroconversion, typically before AIDS. Evaluation of HIV-infected individuals for these lesions has many potential clinical and research benefits, including the possible use of oral lesions as primary end-points in clinical trials.

Kaposi's sarcoma among homosexual and bisexual men enrolled in the San Francisco City Clinic Cohort Study.

The changing epidemiology of Kaposi's sarcoma (KS) and possible explanations for this change were analyzed using data from a well-characterized cohort of homosexual and bisexual men. Among 1,341 men with AIDS, the proportion presenting with KS declined from 79% in 1981 to 25% in 1989. For 250 men whose date of HIV seroconversion could be well characterized, persons presenting with KS had a shorter interval from HIV seroconversion to AIDS diagnosis than other AIDS patients without KS (mean = 77 vs. 86 months). Among 182 men who were interviewed prior to a diagnosis of AIDS, men with and without KS did not significantly differ with respect to number of sex partners, a history of certain sexually transmitted or enteric diseases, use of certain recreational drugs (including nitrite inhalants), or participation in certain specific sexual practices. The decline in KS may at least partly be due to a shorter latency period from infection to disease. Although cofactors for the development of KS may exist, many previously hypothesized agents were not supported by this analysis.

Relationship between AIDS latency period and AIDS survival time in homosexual and bisexual men.

We identified 277 homosexual and bisexual men diagnosed with acquired immune deficiency syndrome (AIDS) whose estimated human immunodeficiency virus (HIV) seroconversion dates, ranging from 1977-85, could be well approximated. These men were from a cohort of 6,705 homosexual and bisexual men originally recruited for studies of sexually transmitted hepatitis B in San Francisco in 1978-80. We compared the time from HIV seroconversion to the initial disease diagnostic of AIDS (AIDS latency period) with the time from first AIDS diagnosis to death (AIDS survival time) and found no significant overall correlation between latency period and survival time. Both Kaplan-Meier and Cox proportional hazard stepwise analyses found the initial AIDS diagnosis to be significantly associated with latency period, with individuals first diagnosed with Kaposi's sarcoma (KS) having a shorter latency but longer survival than those first diagnosed with Pneumocystis carinii pneumonia (PCP) or other AIDS diagnoses. Individuals with KS tended to be diagnosed earlier in the epidemic compared to those with PCP and other non-KS diagnoses. The AIDS survival time was significantly associated with the initial AIDS diagnosis but not with the estimated year of seroconversion, the year of first AIDS diagnosis, age at seroconversion, or racial/ethnic group. The information presented here on the relationship between the AIDS latency period and survival times suggests a model for the pathogenesis of HIV infection in which there is continual deterioration of the immune system. The wider use of antiviral and prophylactic therapies both preceding and following a diagnosis of AIDS may change this model as both latency and survival times are improved.

Use of Bayes theorem to estimate the impact of the proposed CD4-based expansion of the AIDS case definition.

To assess the immediate impact of the proposed CD4-based expansion of the AIDS case definition, we determined two key proportions from a subsample of men from the San Francisco City Clinic Cohort (SFCCC). We then used Bayes theorem to project the number of persons fitting the proposed definition in the entire SFCCC and in the city of San Francisco. Among those men meeting the 1987 AIDS case definition, the proportion with a CD4 cell count < 200 cells (within 6 months of their AIDS diagnosis) is 0.70 (16 of 23). Among those with a CD4 count ever < 200 cells, the proportion with AIDS is 0.40 (29 of 73). Our estimates show that 446 persons in the SFCCC and 3,603 persons in San Francisco would fit only the expanded definition. Thus, the proposed definition would likely more than double the number of persons who could be diagnosed with AIDS. Bayes theorem offers a simple method for estimating the immediate impact of the proposed CD4-based expansion of the AIDS case definition.

Factors associated with incident self-reported AIDS among women enrolled in the women's interagency HIV study (WIHS). WIHS Collaboratorive Study Group.

We evaluated factors associated with incident self-reported AIDS diagnoses among HIV-infected women in the Women's Interagency HIV Study (WIHS). Baseline information included age, race/ethnicity, HIV risk category, site of enrollment, years of education, cigarette smoking, CD4 cell count, and HIV viral load. Baseline and follow-up data on self-reported AIDS were analyzed using chi-square, Kaplan-Meier, and Cox proportional hazard models. Among the 1397 HIV-infected women who reported being free of clinical AIDS at baseline, 335 women (24%) reported an incident AIDS diagnosis during follow-up. In stratified Kaplan-Meier analyses, the development of self-reported AIDS was significantly associated with baseline CD4 cell count and viral load (p<0.01). In multivariate Cox proportional hazard analyses, women were statistically more likely to report AIDS if they had CD4 cell counts below 195 cells/mm3 (p<0.01), HIV RNA >4000 copies/ml (p<0.01), were current smokers (p<0.01), and had "no identifiable risk" for acquisition of HIV (p = 0.03). Self-reports of a clinical AIDS diagnosis may not always be accurate, but laboratory markers of HIV disease indicate that those women who self-report such diagnoses have greater immunodeficiency and a higher viral load when compared with those who report no AIDS-defining diagnoses.

The perinatal advantage of Mexican-origin Latina women.

PURPOSE: To determine if there is a perinatal advantage for birth outcomes among Mexican-origin Latina (Latina) women compared to white non-Hispanic (white) women, after adjusting for maternal, paternal, and infant factors. METHODS: 1,439,583 births from the 1990-1993 California linked birth and infant death certificate data sets were analyzed for the risk of low birth weight infants and infant mortality. RESULTS: Latina women had a statistically higher unadjusted risk of low birth weight infants and infant mortality compared to white women. After adjusting for potential confounders, Latina women had a similar risk of low birth weight infants and a lower risk of infant mortality relative to white women. In multivariate analyses, the most significant risk factor for low infant birth weight was young gestational age (OR = 82.91 for gestational age 1-230 days and OR = 10.62 for gestational age 231-258 days) and the most significant risk factor for infant mortality was low birth weight (OR = 53.99 for infant birth weight <500 grams and OR = 9.27 for infant birth weight 500-2499 grams). CONCLUSION: There was some evidence of a perinatal advantage for Latina women, when compared to white women and after adjusting for numerous potential confounders. To further reduce the risk of low birth weight infants and infant mortality, additional research is needed for etiologic clues beyond race/ethnicity and other traditional risk factors.

Maternal birthplace, ethnicity, and low birth weight in California.

BACKGROUND: Although immigrants to the United States are usually ethnic minorities and socioeconomically disadvantaged, foreign-born women generally have lower rates of low birth weight infants than do US-born women. OBJECTIVE: To measure the relationship between maternal birthplace, ethnicity, and low birth weight infants. DESIGN: Retrospective cohort study of birth certificate data. SETTING: California, 1992. SUBJECTS: Singleton infants (n = 497 868) born to Asian, black, Latina, and white women. MAIN OUTCOME MEASURES: Very low birth weight (500-1499 g), moderately low birth weight (1500-2499 g), and normal birth weight (2500-4000 g, reference category). RESULTS: Foreign-born Latina women generally had less favorable maternal characteristics than US-born Latinas, yet foreign-born Latina women were less likely to have moderately low birth weight infants (odds ratio, 0.91; 95% confidence interval, 0.86-0.96) than US-born Latinas after adjusting for maternal age, education, marital status, parity, tobacco use, use of prenatal care, and gestational age. While foreign-born Asian women generally had a less favorable profile of maternal characteristics than US-born Asians, there was no statistically significant difference in the odds of very low birth weight or moderately low birth weight infants between foreign- and US-born Asian women. Foreign-born black women had more favorable maternal characteristics than US-born women, but there was no significant nativity difference in very low birth weight or moderately low birth weight between foreign- and US-born black women after adjusting for maternal and infant factors. CONCLUSIONS: The relationship between maternal birthplace and low birth weight varies by ethnicity. Further study is needed to understand the favorable pregnancy outcomes of foreign-born Latina women.

Testing the epidemiologic paradox of low birth weight in Latinos.

BACKGROUND: Rates of low-birth-weight (LBW) infants are similar between Latina and white women, an epidemiologic paradox. However, few studies have analyzed the relationship between ethnicity, Latino subgroup, confounding variables, and LBW. METHODS: We analyzed 395070 singleton livebirths to Latina and non-Latina white women in California during 1992. Multivariate logistic regression was used to estimate odds ratios (ORs) and 95% confidence intervals (CIs) for the risks due to Latino ethnicity and Latino subgroup for very LBW (VLBW, 500-1499 g) and moderately LBW (MLBW, 1500-2499 g) outcomes. RESULTS: Latina and white women had similar unadjusted rates of VLBW (0.7% vs. 0.6%) and MLBW infants (3.7% vs. 3.4%). After adjusting for maternal age, education, birthplace, marital status, parity, tobacco use, use of prenatal care, infant sex, and gestational age, there was no difference in the odds of VLBW infants between Latina and white women (OR, 0.93 [95% CI, 0.81-1.071). Latina women had minimally elevated odds of MLBW infants (OR, 1.06 [95% CI, 1.01-1.11]) compared with white women. By Latino subgroup, there was no difference in the adjusted odds of VLBW infants among Central and South American, Cuban, Mexican, Puerto Rican, and white women. The adjusted odds of MLBW infants were elevated among Central and South American (OR, 1.14 [95% CI, 1.05-1.25]) and Puerto Rican women (OR, 1.41 [95% CI, 1.12-1.78]), relative to white women. CONCLUSIONS: The epidemiologic paradox of LBW in Latinos is valid. New conceptual models are needed to identify Latina women who are at risk for adverse pregnancy outcomes.

Interpregnancy interval and the risk of premature infants.

OBJECTIVE: Interpregnancy intervals are associated with the risk of low birth weight (LBW) infants, but the association between interpregnancy interval and prematurity is unknown. Our objective was to determine whether interpregnancy intervals were associated with the risk of premature infants and to define the degree of risk according to interpregnancy interval. METHODS: We analyzed 289,842 singleton infants born to parous Mexican-origin Hispanic and non-Hispanic white women in the United States who resided in the same county and delivered between January 1, 1991 and September 30, 1991. Interpregnancy interval was defined as the number of months between the previous live birth and conception of the index pregnancy. Multivariate logistic regression analysis was used to estimate odds ratios and 95% confidence intervals for the risk of interpregnancy interval on very premature (23-32 weeks), moderately premature (33-37 weeks), and term gestation (38-42 weeks). RESULTS: Nearly 37% of women had interpregnancy intervals less than 18 months, 45.5% of women had intervals of 18-59 months, and 17.6% of women had intervals over 59 months. After adjusting for confounding variables, women with intervals less than 18 months were 14-47% more likely to have very premature and moderately premature infants than women with intervals of 18-59 months. Women with intervals over 59 months were 12-45% more likely to have very premature and moderately premature infants than women with intervals of 18-59 months. CONCLUSION: Women with interpregnancy intervals from 18-59 months had the lowest risk of very premature and moderately premature infants. Further study is needed to define the mechanisms through which interpregnancy interval influences pregnancy outcome.

Risk of low birth weight infants among black and white parents.

OBJECTIVE: To determine whether racial differences in risk of low birth weight infants among black and white parents can be attributed to differences in demographic, behavioral, medical, and socioeconomic factors. METHODS: We analyzed 203,815 singleton births from the 1992 California birth certificate data set for the risk of very low birth weight (500-1499 g) and moderately low birth weight (1500-2499 g) infants. Additional study variables included maternal (race, age, education, marital status, parity, obstetric history, tobacco use, medical complications, medical insurance, and use of prenatal care), paternal (race, age, and education), infant (gestational age and gender), and community (median household income from the 1990 US Census) characteristics. RESULTS: For both very low and moderately low birth weight infants, the unadjusted risk associated with parental race showed a gradient of risk, from highest to lowest, for black mother/black father, black mother/white father, white mother/black father, and white mother/white father parents. After adjusting for other risk factors, the odds ratio associated with black mother/black father parents was reduced from 3.37 to 1.73 for very low birth weight infants and from 2.51 to 1.60 for moderately low birth weight infants, but both remained elevated. Interracial parents no longer had an elevated risk of very low birth weight infants and white mother/black father parents no longer had an elevated risk of moderately low birth weight, compared with white parents. CONCLUSION: After controlling for parental, infant, and community factors, most but not all of the increased risk of low birth weight infants associated with black parental race was explained.

High-risk sexual behavior and knowledge of HIV antibody status in the San Francisco City Clinic Cohort.

To evaluate the effectiveness of human immunodeficiency virus (HIV) testing and counseling among homosexual and bisexual men participating in the San Francisco City Clinic Cohort, compared behavioral data from 181 men who learned their HIV antibody status between 1985 and 1987 with data from 128 men who were tested but declined to receive their results. Overall, significant declines in risk indices for unprotected receptive and insertive anal intercourse occurred between 1983-1984 and 1986-1987, but these declines were independent of both knowledge of HIV status and actual serostatus. Those who chose to learn their HIV status were also no more likely to report depression or to learn their HIV status were also no more likely to report depression or anxiety subsequent to testing. Regression analyses showed no relationship between length of time since learning one's HIV status, mental health symptoms, and the persistence of high-risk behavior in 1986-1987. Although these results do not negate the value of HIV testing and counseling, they suggest that other motivating factors such as frequent access to risk-reduction information may provide sufficient impetus for behavioral change.

Hepatitis C virus infection in sexually active homosexual men.

While hepatitis C virus (HCV) is known to be transmitted parenterally, the role of sexual transmission remains unclear. In order to examine the association of sexual risk factors with HCV seroprevalence at a time when unprotected sexual practices were still quite common, 435 homosexual men recruited from a municipal sexually transmitted disease clinic with behavioural data and serologic specimens from 1983-1984 were evaluated. Overall, 25% of men reporting injecting drug use (IDU) and 5% of men with no IDU were anti-HCV positive; the rate in the non-IDU was significantly higher than age-matched rates in blood donors (summary odds ratio 3.5, 95% confidence interval 2.8-4.2). In addition to IDU, amphetamine and phencyclidine use were also associated with anti-HCV positivity on univariate analysis. Sexual risk factors for anti-HCV positivity included anal receptive intercourse, 'fisting', having an IDU sexual partner, a self-reported history of genital herpes and HIV seropositivity. On multivariate analysis, only IDU was significantly associated with anti-HCV positivity. Thus, sexual practices appear to play a minor role in transmission of HCV.

Course of HIV-I infection in a cohort of homosexual and bisexual men: an 11 year follow up study.

OBJECTIVE--To characterise the natural history of sexually transmitted HIV-I infection in homosexual and bisexual men. DESIGN--Cohort study. SETTING--San Francisco municipal sexually transmitted disease clinic. PATIENTS--Cohort included 6705 homosexual and bisexual men originally recruited from 1978 to 1980 for studies of sexually transmitted hepatitis B. This analysis is of 489 cohort members who were either HIV-I seropositive on entry into the cohort (n = 312) or seroconverted during the study period and had less than or equal to 24 months between the dates of their last seronegative and first seropositive specimens (n = 177). A subset of 442 of these men was examined in 1988 or 1989 or had been reported to have developed AIDS. MAIN OUTCOME MEASURES--Development of clinical signs and symptoms of HIV-I infection, including AIDS, AIDS related complex, asymptomatic generalised lymphadenopathy, and no signs or symptoms of infection. MEASUREMENTS AND MAIN RESULTS--Of the 422 men examined in 1988 or 1989 or reported as having AIDS, 341 had been infected from 1977 to 1980; 49% (167) of these men had died of AIDS, 10% (34) were alive with AIDS, 19% (65) had AIDS related complex, 3% (10) had asymptomatic generalised lymphadenopathy, and 19% (34) had no clinical signs or symptoms of HIV-I infection. Cumulative risk of AIDS by duration of HIV-I infection was analysed for all 489 men by the Kaplan-Meier method. Of these 489 men, 226 (46%) had been diagnosed as having AIDS. We estimated that 13% of cohort members will have developed AIDS within five years of seroconversion, 51% within 10 years, and 54% within 11.1 years. CONCLUSION--Our analysis confirming the importance of duration of infection to clinical state and the high risk of AIDS after infection underscores the importance of continuing efforts both to prevent transmission of HIV-I and to develop further treatments to slow or stall the progression of HIV-I infection to AIDS.

Risk factors for macrosomia in infants born to Latina women.

OBJECTIVE: To assess risk factors for macrosomic infant birth among Latina women. STUDY DESIGN: Prospective study of Latina women recruited during pregnancy from prenatal clinic at San Francisco General Hospital. Information was obtained through a structured interview and review of medical records. RESULT: A total of 11% of women delivered macrosomic infants (birth weight >4000 g). In unadjusted analyses, significant risk factors for macrosomia included older maternal age, increasing gravidity, previous history of macrosomic birth and pre-pregnancy overweight. After adjusting for confounders using multivariate analyses, older mothers (10-year increments) had an elevated risk of macrosomia (odds ratio (OR) 2.59; 95% confidence interval (CI) 1.28 to 5.24). CONCLUSION: Efforts to reduce macrosomia in Latina women should focus on older mothers.