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RESEARCH AND PRACTICE |
Mardge H. Cohen is with the CORE Center, Cook County Hospital, Cook County Bureau of Health Services, Chicago, Ill. Judith A. Cook and Dennis Grey are with the Department of Psychiatry, University of Illinois, Chicago. Mary Young is with the Department of Medicine, Georgetown University Medical Center, Washington, DC. Lawrence H. Hanau is with the Department of Medicine, Montefiore Medical Center, Bronx, NY. Phyllis Tien is with the Department of Medicine, University of California, San Francisco, and San Francisco Department of Veterans Affairs. Alexandra M. Levine is with the Division of Hematology, Keck School of Medicine, University of Southern California, Los Angeles. Tracey E. Wilson is with the Department of Preventive Medicine and Community Health, SUNY Downstate Medical Center, Brooklyn, NY.
Correspondence: Requests for reprints should be sent to Mardge H. Cohen, MD, 2020 W Harrison, Chicago, IL 60612 (e-mail: mcohen{at}corecenter.org).
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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Objectives. We investigated the prevalence and characteristics of HIV-positive women who do not report highly active antiretroviral therapy (HAART) use.
Methods. We analyzed HAART use among 1165 HIV-positive participants in the Women’s Interagency HIV Study.
Results. Between October 1, 2000, and March 31, 2001, 254 women with clinical indications for HAART reported not using it, 635 reported HAART use, and 276 had no clinical indications. In multivariate analysis, using crack/cocaine/heroin and a history of abuse decreased the likelihood of using HAART, whereas being White increased it.
Conclusions. One of 4 women for whom HAART was indicated reported not using HAART. Childhood sexual abuse prevention, more intensive abuse treatment, and continuing drug treatment may enhance HIV disease treatment of women.
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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As HAART regimens become more varied and convenient, it is important to examine why women who are medically eligible for this therapy remain untreated. We report here on the prevalence and predictors of lack of HAART use in 2000–2001 among medically eligible women enrolled in the Women’s Interagency HIV Study (WIHS), a cohort study of women with and at risk for HIV infection, representative of women with HIV in the United States.9
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METHODS |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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A standardized interview-based survey was used to collect demographics; medical and psychosocial history; history of cigarette smoking; alcohol use, illicit drug use (including intravenous drugs and noninjected heroin, crack, and cocaine), and drug treatment programs; sexual history; and history of medication use and reasons for not taking medications at each 6-month visit. Participants were shown photographs of all antiretroviral medications to help increase accurate reporting. The Center for Epidemiological Studies Depression Scale measured depressive symptoms, with a score of 16 or greater indicative of a probable depressive disorder.
Women were considered to have experienced abuse if they answered affirmatively to any questions about physical, sexual, or emotional coercion. For this analysis, a history of abuse included domestic violence, defined as physical or sexual abuse or coercion by an intimate partner or spouse; recent abuse, defined as abuse experienced within the past year; and childhood sexual abuse, defined as sexual abuse that occurred before 18 years of age. Abuse data were not collected at the 2 California sites because of reporting requirements, which would have interfered with participant confidentiality.
WIHS recruited women from HIV care, drug treatment, HIV-testing, and sexually transmitted disease clinic programs. Each research site relates to an HIV care program, to which women are referred if they are not already in care. These comprehensive HIV programs offer obstetric and gynecologic services, and many have on-site or connections to mental health and drug treatment. The WIHS protocol specifically calls for flagging responses to survey questions requiring follow-up or referral to specialized care, particularly for illicit drug use, depression, and domestic violence.10 This ensures that these issues are openly addressed at the end of the interview session.
HIV-1 antibody status, HIV-1 RNA, and CD4 T-lymphocyte (CD4) counts were determined at each visit. HIV-1 RNA quantitation was performed using the isothermal nucleic acid sequence-based amplification method in laboratories certified by the National Institutes of Health (NIH) Virology Quality Assurance program, and CD4 counts were determined using standard flow cytometric techniques at local laboratories certified by the NIH Quality Assurance Program. Baseline hepatitis C antibody assays were performed locally.
HAART use was determined by self-report and defined as (1) 2 or more nucleoside reverse transcriptase inhibitors (NRTIs) in combination with at least 1 protease inhibitor (PI) or 1 non-nucleoside reverse transcriptase inhibitor (NNRTI); (2) 1 NRTI in combination with at least 1 PI and at least 1 NNRTI; (3) a regimen containing ritonavir and saquinavir in combination with 1 NRTI and no NNRTIs; and (4) an abacavircontaining regimen of 3 or more NRTIs in the absence of both PIs and NNRTIs. Combinations of zidovudine (AZT) and stavudine (d4T) with either a PI or NNRTI were not considered HAART. All other antiretroviral regimens were classified as mono or combination therapy. Participants reporting no HAART use may have used the therapy at some time in the past but were not using it at the analyzed study visit.
HAART was considered to be clinically indicated among those women who reported using HAART and those women with a CD4 count less than 350 or a viral load greater than 50 000 (per the published treatment standards in use during the studied visit).11
Statistical Methods
Analysis of variance was used to test for significant differences between 3 groups of women: those using HAART, those for whom HAART was clinically indicated but who were not using it, and those for whom HAART was not indicated, in terms of a series of respondent background features. Next, multiple logistic regression analysis was used to predict lack of HAART use at study visit 13 (i.e., study visits and interviews occurring between October 1, 2000, and March 31, 2001) among all women for whom HAART was clinically indicated at any time before that study visit. Finally, to study a larger "HAART initiation window," multiple logistic regression analysis was used to model predictors of not using HAART at any of the 3 study visits 11, 12, and 13 among all women for whom HAART was clinically indicated at study visit 10. This latter analysis was limited to women who had at least 18 to 24 months to initiate HAART, as opposed to the first analysis, in which women could have had a minimum of only 6 months for HAART initiation. As data on abuse were not available from California participants, they were not included in the multivariate analyses. We performed a 
2 test to examine the association between current drug use and drug treatment.
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RESULTS |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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The demographic and behavioral characteristics for these 3 groups are shown in Table 1
. Women in the groups did not differ significantly in median age, in the proportions completing high school, or in having high levels of depressive symptoms. Analysis of variance indicated that a significantly lower percentage of African American women were using HAART, whereas a higher percentage of White women reported using HAART. A lower percentage of women with a history of past and current use of crack, cocaine, or heroin were using HAART. A lower percentage of women with a history of physical or sexual abuse reported using HAART. Similarly, a lower percentage of women with hepatitis C reported using HAART. A higher percentage of women with private insurance and of women currently working reported HAART use.
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, current crack, cocaine, or heroin use, being non-White, and experiencing any physical or sexual abuse increased the likelihood of no HAART use among clinically eligible women. Women who used crack, cocaine, or heroin in the past year were more than twice as likely to report lack of HAART use, even when indicated (odds ratio [OR] = 2.1, 95% confidence interval [CI]= 1.17, 3.79). Similarly, women with a history of any physical/sexual abuse were more than 1.5 times more likely to lack HAART (OR = 1.72, 95% CI = 1.07, 2.77) when clinically eligible. Finally, White women were half as likely to be non-HAART users (OR = 0.45, 95% CI = 0.215, 0.956).
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). Here, too, the model showed that being White predicted using HAART, whereas women with any physical or sexual abuse and with current crack, cocaine, or heroin use were significantly more likely to be HAART nonusers, after we controlled for all other factors.
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Women for whom HAART was indicated but who were using no therapy were asked to list the main reason they were not using any therapies. Only 15% reported, "My doctor did not prescribe them," whereas the rest answered that they felt too healthy, wanted to wait, were afraid of side effects, or had difficulty taking the medicines.
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DISCUSSION |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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A history of physical, sexual/childhood abuse is common in women with HIV infection, with up to two thirds reporting a lifetime experience with abuse.12–14 Considering this high prevalence of abuse, our finding that women who had been abused were more than 1.5 times more likely to report not using HAART is sobering. This association of abuse and not using HAART has not been reported in previous studies. Felitti et al.15 have shown the association of childhood sexual abuse and other adverse childhood exposures to increased health risks for alcoholism, drug abuse, depression, and suicide, as well as to the presence in adulthood of heart disease, cancer, lung disease, skeletal fractures, and liver disease. We can now add suboptimal HIV treatment to this list.
Studies have demonstrated that women with a history of abuse characterize their relationships with medical providers as less satisfactory than women without a history of abuse.16 They are more likely to consider the provider as judgmental, annoyed, and disrespectful and find it difficult to discuss private and emotional issues with their providers. Thus, women with a history of abuse rarely acknowledge this abuse during their medical encounters. These less than satisfactory relationships may explain in part why women with HIV and a history of abuse are more likely not to use HAART. In addition, experiences of abusive relationships may be responsible for damaged self-image, which may become an obstacle to efficacious self-care practices. Leenerts17 describes how "lingering images" of a damaged self grow out of abuse and can produce disconnection from self-care. This combination of an inability to trust health providers and the personal barriers to effective self-care associated with abuse and the sequelae of posttraumatic stress disorder may lead women to decline HAART when it is offered. It is also possible that medical providers may not offer HAART to these women because of concerns regarding emotional instability/adherence to HAART. Certainly the relationship between a woman with a history of abuse and her medical provider requires more investigation if the impact of abuse on HAART use is to be fully understood.
Our study also found that women who were current users of crack, cocaine, or heroin were twice as likely to report not using HAART when medically indicated. The relation of drug use to lack of HAART has been noted in earlier studies.18–20 The need to encourage physicians to offer all patients appropriate life-extending therapy while providing resources and plans to address barriers to HIV adherence remains a pressing concern.21 Although those in drug treatment programs and those with previous drug use seem to respond to HAART similarly to those who have never used illicit drugs, current injection drug users and cocaine users require intensive support to adhere to HAART.22,23 Studies of women with both drug use and abuse consistently show poorer drug treatment outcomes and the need for more tailored and intensive dual-directed therapy.24
In its 2001 discussion of health system challenges, the Institute of Medicine reported: "Some problems—such as substance abuse, AIDS, and domestic violence—are so interrelated that they appear to require a comprehensive rather than problem-by-problem approach."25(p134) Although residential drug treatment programs for HIV-infected women are available, the pattern of drug addiction often means that women relapse even when treatment has been available. And although advocacy related to abuse and history of child sexual abuse are available, very few intensive residential treatment programs for abuse exist. Mental health services within the public sector (where most of the women with HIV get their care) are also notoriously inadequate.
The WIHS was designed to allow women to honestly report behaviors they might not otherwise disclose and to provide referrals for identified problems. The remarkably high adherence rates to study visits, more than 80% after 5 years,26 attest to the success of this approach. WIHS staff continually provide opportunities for advocacy and treatment for psychosocial problems as shown by the high percentage of drug users in treatment programs. For some women, competing priorities prevent them from choosing these options. Thus, even when an observational cohort is followed within the context of women-centered HIV comprehensive programs and is provided with advocacy and treatment referrals for domestic violence and drug use, we found a continuing significant impact of these issues on women using HAART.
Being non-White was also significantly associated with not using HAART when medically indicated. With the burden of HIV in US women borne by African Americans and Latinas, it is particularly striking to document that race remains predictive of lack of appropriate therapy.27 This predictable but hardly acceptable finding cries out for more effective strategies to overcome this racial gap in HAART use, especially considering that the primary goal of The Healthy People 2010 Initiative is to eliminate disparities in health care in our country.28 Recent data confirm that the average life expectancy of African Americans is 6 years less than that of Whites in the United States, with HIV infection, hypertension, diabetes, and trauma responsible for most of this disparity.29
There are some limitations to our study. The data provided are from self-reports and not confirmed by chart review or provider surveys. We cannot tell from our database if there were other medical or nonmedical conditions that providers considered contraindications to the participants’ HAART use. The first cross-sectional analysis only allowed us to evaluate HAART use in 1 time period, from 2000 through 2001, and some of these women had been using HAART in the past and discontinued their medications before the studied visit. However, in the second analysis, we evaluated data longitudinally in the subset of women who were not using HAART between 1999 and 2001, and our conclusions are strengthened by the fact that both analyses yielded similar results.
In conclusion, our study suggests that a history of childhood or adult sexual/physical abuse; current crack, cocaine, or heroin use; and racial status are important predictors of appropriate HIV medication use. Through acknowledgment of these challenges and innovative collaborations with mental health, substance use, and abuse experts, HIV providers have an opportunity to more effectively treat all women with HIV infection. But the public health community has an obligation, as well, to assist these efforts by advocating for more comprehensive drug treatment programs, new intensive residential abuse programs, and more successful childhood sexual abuse prevention campaigns.
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Acknowledgments |
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Data in this manuscript were collected by the Women’s Interagency HIV Study Collaborative Study Group with centers (principal investigators) at New York City/Bronx Consortium (Kathryn Anastos); Brooklyn, NY (Howard Minkoff); Washington, DC Metropolitan Consortium (Mary Young); The Connie Wofsy Study Consortium of Northern California (Ruth Greenblatt, Phyllis C. Tien); Los Angeles County/Southern California Consortium (Alexandra Levine); Chicago Consortium (Mardge Cohen); Data Coordinating Center (Alvaro Muñoz, Stephen J. Gange).
Human Participant Protection
We obtained informed consent from the participants in accordance with procedures and consent materials reviewed and approved by the committee on human experimentation at each of the collaborative institutions.
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Footnotes |
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Accepted for publication September 3, 2003.
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References |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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2. Whitman S, Murphy J, Cohen M, Sherer R. Marked declines in human immunodeficiency virus—related mortality in Chicago in women, African Americans, Hispanics young adults, and injection drug users, from 1995–1997. Arch Intern Med. 2000;160:365–369.
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4. Gange SJ, Barron Y, Greenblatt RM, et al. Effectiveness of highly active antiretroviral therapy among HIV-1 infected women. J Epidemiol Community Health. 2002;56:153–159.
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8. Garner LI, Holmberg SD, Moore J, et al. Use of highly active antiretroviral therapy in HIV-infected women: impact of HIV specialist care. J Acquir Immune Defic Syndr. 2002;29:69–75.
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13. Vlahov D, Wientge D, Moore J, et al. Violence among women with or at risk for HIV infection. AIDS Behav. 1998;2:53–60.
14. Gielen AC, McDonnell KA, Wu AW, et al. Quality of life among women living with HIV: the importance of violence, social support and self care behaviors. Soc Sci Med. 2001;52:315–322.
15. Felitti VJ, Anda RF, Nordenberg D, et al. Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACE). Am J Prev Med. 1998;14:245–258[ISI][Medline]
16. McNutt L, van Ryn M, Clark C, Frasier I. Partner violence and medical encounters: African American women’s perspectives. Am J Prev Med. 2000;19:264–269.[ISI][Medline]
17. Leenerts MH. The disconnected self: consequences of abuse in a cohort of low-income white women living with HIV/AIDS. Health Care Women Int. 1999;20:381–400.[Medline]
18. Bassetti S, Battegay M, Furrer H, et al. Why is highly active antiretroviral therapy not prescribed or discontinued? Swiss HIV Cohort Study. J Acquir Immune Defic Syndr. 1999;21:114–119.
19. Bogart LM, Kelly JA, Catz SL, Sosman JM. Impact of medical and non-medical factors on physician decision making for HIV/AIDS antiretroviral treatment. J Acquir Immune Defic Syndr. 2000;23:396–404.
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21. Maisels L, Steinberg J, Tobias C. An investigation of why eligible patients do not receive HAART. AIDS Patient Care STDS. 2001;15:185–191.[ISI][Medline]
22. Lucas GM, Cheever LW, Chaisson RE, Moore RD. Detrimental effects of continued illicit drug use on the treatment of HIV-1 infection. J Acquir Immune Defic Syndr. 2001;27:251–259.
23. Arnsten JH, Demas PA, Grant RW, et al. Impact of active drug use on antiretroviral therapy adherence and viral suppression in HIV-infected drug users. J Gen Intern Med. 2002;17:377–381.[ISI][Medline]
24. Ouimette PC, Brown PJ, Najavits LM. Course and treatment of patients with both substance use and posttraumatic stress disorders. Addict Behav. 1998;23:785–795.[ISI][Medline]
25. Institute of Medicine (IOM). Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academies Press; 2001:134.
26. Hessol NA, Schneider M, Greenblatt RM, et al. Retention of women enrolled in a prospective study of human immunodeficiency virus infection: impact of race, unstable housing, and use of human immunodeficiency virus therapy. Am J Epidemiol. 2001;154:563–573.
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29. Wong MD, Shapiro MF, Boscardin J, Ettner SL. Contribution of major diseases to disparities in mortality. N Engl J Med. 2002;347:1585–1592.
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| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
