Beyond Viral Suppression - The Impact of Cumulative Violence on Health-Related Quality of Life among a Cohort of Virally Suppressed Patients

Objective:To elucidate how and in what ways cumulative violence affects health-related quality of life (HRQoL) among a clinical cohort of virally stable people living with HIV.Design:We used data from the University of North Carolina Center for AIDS Research HIV clinical cohort. Our analysis was limited to participants with an undetectable viral load (<200) and those who completed the Clinical, Sociodemographic, and Behavioral Survey between 2008 and 2017 (n = 284).Methods:A path analysis was used to test our primary hypothesis that the effect of cumulative violence on HRQoL would be mediated through symptoms of post-traumatic stress disorder (PTSD), depressive symptoms, and HIV symptom distress.Results:The impact of cumulative violence on HRQoL was fully mediated by symptoms of PTSD, depressive symptoms, and HIV symptom distress. Greater exposure to violence was associated with higher odds of PTSD symptoms (P <0.001), increased depressive symptoms (P <0.001), and increased HIV symptom distress (P < 0.01). HIV symptom distress displayed the largest association with HRQoL (P < 0.001), followed by depressive symptoms (P = 0.001) and PTSD symptoms (P < 0.001). These factors explained approximately 51% of the variance in HRQoL (R2= 0.51, P < 0.001).Conclusions:Our findings indicate that addressing physical and mental health symptoms rooted in violent victimization should be a point of focus in efforts to improve HRQoL among people living with HIV who are virally stable

Comparative effectiveness of dual vs. single-action antidepressants on HIV clinical outcomes in HIV-infected people with depression

Objective: Depression is highly prevalent among people living with HIV/AIDS (PLWHA) and has deleterious effects on HIV clinical outcomes. We examined changes in depression symptoms, viral suppression, and CD4 + T cells/μl among PLWHA diagnosed with depression who initiated antidepressant treatment during routine care, and compared the effectiveness of dual-action and single-action antidepressants for improving those outcomes. Design: Comparative effectiveness study of new user dual-action or single-action antidepressant treatment episodes occurring from 2004 to 2014 obtained from the Center for AIDS Research Network of Integrated Clinical Systems. Methods: We identified new user treatment episodes with no antidepressant use in the preceding 90 days. We completed intent-to-treat and per protocol evaluations for the main analysis. Primary outcomes, were viral suppression (HIV viral load <200 copies/ml) and CD4 + T cells/μl. In a secondary analysis, we used the Patient Health Questionnaire-9 (PHQ-9) to evaluate changes in depression symptoms and remission (PHQ <5). Generalized estimating equations with inverse probability of treatment weights were fitted to estimate treatment effects. Results: In weighted intent-to-treat analyses, the probability of viral suppression increased 16% after initiating antidepressants [95% confidence interval=(1.12, 1.20)]. We observed an increase of 39 CD4 + T cells/μl after initiating antidepressants (30, 48). Both the frequency of remission from depression and PHQ-9 scores improved after antidepressant initiation. Comparative effectiveness estimates were null in all models. Conclusion: Initiating antidepressant treatment was associated with improvements in depression, viral suppression, and CD4 + T cells/μl, highlighting the health benefits of treating depression in PLWHA. Dual and single-action antidepressants had comparable effectiveness

Who Will Show? Predicting Missed Visits Among Patients in Routine HIV Primary Care in the United States

Missed HIV medical visits predict poor clinical outcomes. We sought to identify patients at high risk of missing visits. We analyzed 2002–2014 data from six large US HIV clinics. At each visit, we predicted the likelihood of missing the next scheduled visit using demographic, clinical, and patient-reported psychosocial variables. Overall, 10,374 participants contributed 105,628 HIV visits. For 17% of visits, the next scheduled appointment was missed. The strongest predictor of a future missed visit was past-year missed visits. A model with only this predictor had area under the receiver operator curve = 0.65; defining “high risk” as those with any past-year missed visits had 73% sensitivity and 51% specificity in correctly identifying a future missed visit. Inclusion of other clinical and psychosocial predictors only slightly improved performance. Past visit attendance can identify those at increased risk for future missed visits, allowing for proactive allocation of resources to those at greatest risk

The Impact of Cumulative Depression Along the HIV Care Continuum in Women Living with HIV during the Era of Universal Antiretroviral Treatment

Background: Data are limited on cumulative impacts of depression on engagement in care and HIV outcomes in women living with HIV (WLWH) during the era of universal antiretroviral therapy (ART). Understanding the relationship of accumulated depression with HIV disease management may help identify benefits of interventions to reduce severity and duration of depressive episodes. Setting: A cohort of WLWH (N = 1491) from the Women's Interagency HIV Study at 9 sites across the US.Methods:This longitudinal observational cohort study (2013-2017) followed WLWH for a maximum of 9 semiannual visits. Depression was quantified as a time-updated measure of percent of days depressed (PDD) created from repeated assessments using the Center for Epidemiologic Studies Depression scale. Marginal structural Poisson regression models were used to estimate the effects of PDD on the risks of missing an HIV care appointment, <95% ART adherence, and virological failure (≥200 copies/mL). Results: The risk of missing an HIV care appointment [risk ratio (RR) = 1.16, 95% confidence interval = 0.93 to 1.45; risk difference (RD) = 0.01, -0.01 to 0.03], being <95% ART adherent (RR = 1.27, 1.06-1.52; RD = 0.04, -0.01 to 0.07), and virological failure (RR = 1.09, 1.01-1.18; RD = 0.01, -0.01 to 0.03) increased monotonically with increasing PDD (comparing those with 25 to those with 0 PDD). The total effect of PDD on virological failure was fully (%100) mediated by being <95% ART adherent. Conclusions: Time spent depressed increases the risk of virological failure through ART adherence, even in the era of universal ART regimes forgiving of imperfect adherence

Cumulative burden of depression and all-cause mortality in women living with human immunodeficiency virus

Background Research linking depression to mortality among people living with human immunodeficiency virus (PLWH) has largely focused on binary "always vs never" characterizations of depression. However, depression is chronic and is likely to have cumulative effects on mortality over time. Quantifying depression as a cumulative exposure may provide a better indication of the clinical benefit of enhanced depression treatment protocols delivered in HIV care settings. Methods Women living with HIV (WLWH), naive to antiretroviral therapy, from the Women's Interagency HIV Study were followed from their first visit in or after 1998 for up to 10 semiannual visits (5 years). Depressive symptoms were assessed using the Center for Epidemiologic Studies Depression (CES-D) scale. An area-under-the-curve approach was used to translate CES-D scores into a time-updated measure of cumulative days with depression (CDWD). We estimated the effect of CDWD on all-cause mortality using marginal structural Cox proportional hazards models. Results Overall, 818 women contributed 3292 woman-years over a median of 4.8 years of follow-up, during which the median (interquartile range) CDWD was 366 (97-853). Ninety-four women died during follow-up (2.9 deaths/100 woman-years). A dose-response relationship was observed between CDWD and mortality. Each additional 365 days spent with depression increased mortality risk by 72% (hazard ratio, 1.72; 95% confidence interval, 1.34-2.20). Conclusions In this sample of WLWH, increased CDWD elevated mortality rates in a dose-response fashion. More frequent monitoring and enhanced depression treatment protocols designed to reduce CDWD may interrupt the accumulation of mortality risk among WLWH

Indução de embriogênese somática em cupuaçu (Theobroma grandiflorum Schum.) Induction of somatic embryogenesis in cupuassu (Theobroma grandiflorum Schum.)

Folhas jovens de cupuaçu (Theobroma grandiflorum Schum.) foram empregadas para indução de embriogênese somática, as quais foram cultivadas inicialmente em meio MS suplementado com 6,0 mg/L BAP e 0,5 mg/L AIA (meio de estabelecimento), seguindo-se o cultivo em meio MS suplementado com 2,20 mg/L TDZ (meio de indução). A região da nervura mostrou intumescimento três dias após inoculação no meio de estabelecimento, o qual foi seguido pela formação de cachos de calos. As massas calosas foram transferidas para o meio de indução, e as estruturas com características pró-embriogênicas puderam ser observadas após uma semana. Estudos de microscopia eletrônica de varredura revelaram estruturas com características de embriões somáticos no meio com TDZ.<br>Young leaves of cupuassu (Theobroma grandiflorum Schum.) were used to induce somatic embryogenesis, which were cultivated initially in MS basal medium suplemented with 6.0 mg/L BAP and 0.5 mg/L IAA (established medium ) followed by MS basal medium supplemented with 2,20 mg/L TDZ (induction medium). Vascular region of explants showed intumescement three days after inoculation in established medium, which was followed by the formation of calli clusters. Calli mass were transferred to induction medium, and the structures with proembryogenic characteristics could be observed after one week. Scanning electron microscopy studies revealed structures with somatic embryos characteristics in the medium with TDZ