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Caring for Women with HIV Through the Life Course

Caring for Women with HIV Through the Life Course. Mardge Cohen MD PI, Women’s Interagency HIV Study Departments of Medicine, Cook County Health and Hospitals System and Rush University, Chicago IL Boston Health Care for the Homeless Program. Our Challenge.

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Caring for Women with HIV Through the Life Course

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  1. Caring for Women with HIV Through the Life Course Mardge Cohen MD PI, Women’s Interagency HIV Study Departments of Medicine, Cook County Health and Hospitals System and Rush University, Chicago IL Boston Health Care for the Homeless Program

  2. Our Challenge Early antiretroviral (ART) initiation reduces rates of HIV sexual transmission and clinical events (HPTN 052 study) Women 50% of persons living with HIV globally Public health imperative: -Understand how women start, stay on and respond to ART -Assess how this therapy impacts HIV/AIDS and HIV associated non AIDS (HANA) conditions -Support women with HIV to enable longer and healthier lives throughout the life cycle Cohen MS, et al. Prevention of HIV-1 infection with early antiretroviral therapy. N Engl J Med. 2011. UNAIDS. UNAIDS Data Tables. 2011 [updated 2011; cited 2011 December 2, 2011]; Available from:.

  3. Overview Epidemiology and Disparities related to treatments and outcomes Special issues through the life course of women with HIV Emerging diseases/risk factors and importance of inflammation Management: Prognostic Score Card Patient empowerment Enhancing Provider Focus Policy implications

  4. HIV-infected persons in the U.S.– only a fraction getting adequate treatment Centers for Disease Control and Prevention (CDC). Centers for Disease Control and Prevention (CDC). Vital signs: HIV prevention through care and treatment--United States. MMWR Morb Mortal Wkly Rep. 2011 Dec 2;60:1618-23.MMWR Morb Mortal Wkly Rep. 2011 Dec 2;60:1618-23.

  5. Women and African Americans are less likely to have viral suppression Centers for Disease Control and Prevention (CDC). Centers for Disease Control and Prevention (CDC). Vital signs: HIV prevention through care and treatment--United States. MMWR Morb Mortal Wkly Rep. 2011 Dec 2;60:1618-23.MMWR Morb Mortal Wkly Rep. 2011 Dec 2;60:1618-23. • 79% of males had viral suppression, compared with 71% of females. • 84% of whites, 79% of Hispanics/Latinos had documented viral suppression, compared with 70% of African Americans.

  6. African Americans and Latinas have higher rates of new HIV infections, AIDS dx. & mortality HAART has not reduced these racial disparities

  7. Generalized HIV Epidemic in Washington DC • Study of 750 participants • 61% were ≥ 30 years of age • 92% African-American • 60% with annual household income ≤ $10 000 • 5.2% screened HIV+ • women more likely to screen HIV+ than men (6.3 vs 3.9%) • 47% did not know their status prior to study Magnus M, Kuo I, Shelley K, Rawls A, Peterson J, Montanez L, West-Ojo T, Hader S, Hamilton F, Greenberg AE. Risk factors driving the emergence of a generalized heterosexual HIV epidemic in Washington, District of Columbia networks at risk. AIDS. 2009 Jun 19;23(10):1277-84.

  8. Excess Vulnerability to HIV Acquisition Among African American Women socioeconomic inequality lower health literacy inadequate access to high-quality health care high-risk environments Stone VE. HIV/AIDS in Women and Racial/Ethnic Minorities in the U.S. Curr Infect Dis Rep. 2012 Feb;14(1):53-60. Lillie-Blanton M, et al. Association of Race, Substance Abuse, and Health Insurance Coverage With Use of Highly Active Antiretroviral Therapy Among HIV-Infected Women, 2005. Am J Public Health. 2010 August; 100(8): 1493–1499. Jones AS, et al. Multi-Dimensional Risk Factor Patterns Associated with Non-use of HAART among HIV-Infected Women. Womens Health Issues. 2010 September; 20(5): 335–342. Mariam Aziz and Kimberly Y. Smith. Challenges and Successes in Linking HIV-Infected Women to Care in the United States. Clin Infect Dis. (2011) 52 (suppl 2): S231-S237.

  9. Women and Children with HIVProgram at Cook County--1987 Women as share of prevalent AIDS cases • Began single site program • Comprehensive medical (ob/gyne) psychosocial care • Women & children together • Drug Treatment, mental health, domestic violence & legal counseling • Address multiple vulnerabilities • Childcare, transportation, case management • Flexible appointments • Support groups • Peer education programs • “Ambience of caring”

  10. Through the Life Course of Women

  11. Young Women and Adolescents • Increased susceptibility for transmission (biologic, age discrepant sexual partners, coercion, transactional sex, poverty, racism) • Poor ART adherence • Psychosocial, gynecologic & medical problems • Need full medical and psychosocial care including sexual & reproductive counseling, contraception and obstetric services

  12. HIV postexposure prophylaxis (PEP) among sexually assaulted adolescent females • Provision/uptake/adherence to PEP • Characteristics 386 youth • Single (94.5%), living with family (68.0%), in school (67.4%) • 42.7% accepted; 33.6% completed 28-day PEP • Factors associated with PEP acceptance • health care provider encouragement • being a student • being moderately-to-highly anxious. Du Mont J, Myhr TL, Husson H, Macdonald S, Rachlis A, Loutfy MR. HIV postexposure prophylaxis use among Ontario female adolescent sexual assault victims: a prospective analysis. Sex Transm Dis. 2008 Dec;35(12):973-8.

  13. Poor ART Adherence in Adolescents with HIV • Correlates with • poor self-efficacy • psychological distress • needing a break from medications • not seeing a need for medications • Interventions to improve adherence • Emphasize benefits of taking medications and expectations of physical symptoms • Boost self-efficacy (e.g., motivational interventions) and reduce emotional distress (e.g., cognitive behavioral therapy) Garvie PA, et al. Pediatric AIDS Clinical Trials Group (PACTG) P1036B Team. Psychological factors, beliefs about medication, and adherence of youth with human immunodeficiency virus in a multisite directly observed therapy pilot study. J Adolesc Health. 2011 Jun;48(6):637-40. Macdonell KE, et al. Situational temptation for HIV medication adherence in high-risk youth. AIDS Patient Care STDS. 2011 Jan;25(1):47-52

  14. Poor Care for Women with HIV • Databases from South Carolina Medicaid & HIV/AIDS reporting system were linked. • 1543 women 18-64 yrs. • 78.3% were black, 75.7% were single • 52% were 25-55 years old; 12% 18-24 years old • 563 women (36.5%) had no Pap test from 1/2005- 12/2009 • Of these, 364 (64.7%) dx with HIV before 2005 Wigfall LT, Brandt HM, Duffus WA, et al. HPV and cervical cancer prevention and control among financial disadvantaged women living with HIV/AIDS in South Carolina. 2nd International Workshop on HIV & Women. January 9-10, 2012, Bethesda, Maryland. Abstract O_07.

  15. Sexual Health of Women with HIV 1805 women (1279 HIV+ and 526 HIV-) completed Female Sexual Function Index (FSFI) Women with HIV reported greater sexual problems than HIV- Women reported ↓ sexual function if they were menopausal, had depressive symptoms, or were not in a relationship. Women with CD4+ <200 had ↓ scores on FSFI Wilson TE, et al. Posted: HIV Infection and Women's Sexual Functioning. J Acquir Immune Defic Syndr. 2010;54(4):360-367.

  16. Impact of Menopause Increases osteopenia and osteoporosis Dyslipidemia Metabolic Changes Weight Changes Cardiac Risk Inflammation/immune response

  17. Chronic Diseases associated with Aging More women with HIV are living longer Longer time on ART Larger burden of chronic disease Impact of comorbidities (cardiovascular, cancer, liver disease, bone disease, kidney disease) Long term immune suppression and inflammatory state from HIV may cause “premature aging” where these diseases of aging occur earlier

  18. Proportionate Causes of Death in HIV+ Women in WIHS French AL, Gawel SH, Hershow R, Benning L, Hessol NA, Levine AM, Anastos K, Augenbraun M, Cohen MH. Trends in Mortality and Causes of Death among Women with HIV in the US: A Ten-year Study. Acquir Immune Defic Syndr. 2009 August 1; 51(4): 399–406.

  19. Cardiovascular Disease • Women with HIV - ↑cardiac risk factors: smoking, hypertension, obesity, diabetes • HIV and ART agents associated with atherosclerosis • ART may worsen CV risk independently of lipid effect • Low CD4+(<200) ↑ subclinical carotid atherosclerosis and ↓ carotid distensibility • Untreated HIV infection can cause immune activation, accelerated immunologic aging & emergence of population of potentially dysfunctional immunosenescent T cells, which may be causally associated with premature onset of CVD Sax PE. Assessing risk for cardiovascular disease in patients with human immunodeficiency virus: why it matters. Circulation. 2010 Feb 9;121(5):620-2 . Hsue PY, et al. Role of Viral Replication, Antiretroviral Therapy, and Immunodeficiency in HIV- Associated Atherosclerosis AIDS. 2009 June 1; 23(9): 1059–1067. Triant VA, et al. Association of C-reactive protein and HIV infection with acute myocardial infarction. J Acquir Immune DeficSyndr. 2009;51:268-273. Kaplan RC et al Low CD4+ T-cell Count as a Major Atherosclerosis Risk Factor in HIV-infected Women and Men. AIDS. 2008;22(13):1615-1624. Seaberg et al. Stroke 2010. Kaplan RC, et al. T-cell senescence and T-cell activation predict carotid atherosclerosis in HIV-infected women. CROI 2010.

  20. Liver Disease (HCV) • Increased liver fibrosis and mortality with HCV/HIV coinfection • Need to diagnose and refer for treatment for HCV. • Need to discourage alcohol use which increases morbidity and mortality • Inflammatory markers increased in HIV/HCV coinfected patients

  21. Cancer • No evidence of breast cancer occurring at earlier ages among HIV-infected women, compared to HIV-uninfected women • Lung Cancer incident rates similar in HIV+ & HIV– women • Lung cancer ↑ in HIV+ and HIV - women compared with population expectations, but not by HIV status • Lung cancer incidence rates similar in pre-HAART & HAART eras • ↑ risk of lung cancer with cumulative tobacco exposure • WIHS women more likely to smoke than similar US women Hessol NA, et al. Cancer Risk Among Participants in the Women's Interagency HIV Study JAIDS Journal of Acquired Immune Deficiency Syndromes:2004;36: 978-985 Levine, et al. HIV As a Risk Factor for Lung Cancer in Women: Data From the Women's Interagency HIV Study. JCO March 20, 2010 vol. 28 no. 9 1514-1519

  22. Bone Mineral Density (BMD) in HIV Borderiii M et al Metabolic bone disease in HIV infection AIDS 2009;23”\:1297-1310 Triant VA et al. J ClinEndocrinaolMetab. 2008;93(9):3502 Ding et al. Circulating Levels of Inflammatory Markers Predict Change in Bone Mineral Density and Resorption in Older Adults: A Longitudinal Study. Journal of Clinical Endocrinology & Metabolism. 2008; 93:1952-1958 • Low BMD in younger and older HIV+ • Osteoporosis 3x higher among HIV+ patients • BMD ↓ 2%–6% in first 2 years after starting ART, similar to decline in first 2 years of menopause. • ↑ fracture rates in HIV+ with rates 30%–70% higher than those among HIV- • Inflammatory markers (Il-6 especially) associated with bone loss in aging and ↓ estrogen

  23. Psychosocial Comorbidities and High Risk Behaviors

  24. Depression Impacts Mortality and Disease Progression • Depressive Symptoms >60% WIHS women • AIDS-related deaths more likely among women with chronic depressive symptoms • Mental health service use associated with ↓ mortality Cook JA, et al. Depressive Symptoms and AIDS-Related Mortality Among a Multisite Cohort of HIV-Positive Women American Journal of Public Health 2004;94:1133- 1140

  25. Cigarette Smoking 53% of HIV+ women in WIHS smoke cigarettes 16% reported tobacco cessation at year 10 (annual sustained cessation rate of 1.8%) Smoking associated with ↓ adherence, many Co-morditiies (lung cancer, CV disease) Goldberg D, et al. Smoking Cessation Among Women with and at Risk for HIV: Are They Quitting? Journal of General Internal Medicine 2010;25:39-44 Feldman JG, et al. Association of Cigarette Smoking With HIV Prognosis Among Women in the HAART Era: A Report From the Women's Interagency HIV Study. American Journal of Public Health. 2006;96(6):1060-1065

  26. Association of recent abuse with mortality • History of GBV of 67% in WIHS Cohort, with 1/3 reporting Childhood Sexual Abuse • Women who experienced abuse within past year twice as likely to die than those without abuse • Women with >2 abuse episodes during WIHS 2½ times more likely to die than those without abuse

  27. Alcohol • Associated with decreased adherence to ART • Increases mortality from HCV • Increases inflammatory state Cook RL, et al. Longitudinal Trends in Hazardous Alcohol Consumption Among Women With Human Immunodeficiency Virus Infection, 1995–2006 Am J Epidemiol. 2009 April 15; 169(8): 1025–1032

  28. Traditional Gender Roles Brody, L.R., Dale, S., Kelso, G., Cruise, R., Weber, K., Watson, C.,Stokes, L., & Cohen, M. (In press). Gender roles and coping in relation to depression and quality of life in women with and at risk for HIV.  In S. Dworkin , P. Passano ,  & Gandhi (Eds). InJustice and In Health: A New Era in Women’s Health and Empowerment. California: UC Press. • Traditional gender norms • women have subordinate/submissive role in relation to men • prioritize care for others over self-care • use passive, not active coping strategies, including sacrificing self-needs to care for others; self-silencing to avoid conflict, violence and relational loss. • The Traditional Gender Roles Substudy Results: • Women with HIV significantly more traditional gender roles, higher levels of self-silencing in relationships; less decision making power in sexual relationships • More traditional gender roles, including having lower power in relationships, as well as lower levels of self-silencing are related to • ↑depression • ↓disclosure, resilience, treatment adherence • ↑ CHD risk

  29. Chicago WIHS HIV+ Cohort characteristics by survival status

  30. Smoking, depression, abuse and alcohol impact Inflammation • Smoking has a significant effect on IL-6 • Depression and CRP, IL-1, and IL-6 are positively associated. • Stress and history of childhood abuse and trauma has been shown to ↑IL-6 and induce telomere shortening • Large amounts of alcohol may adversely affect inflammatory markers de MaatMPM. The association between inflammation markers, coronary artery disease and smoking. Vascular Pharmacology.2002;39: 137-139 Howren MB Associations of depression with C-reactive protein, IL-1, and IL-6: a meta-analysis. Carpenter LL,etal. Association between Plasma IL-6 Response to Acute Stress and Early-Life Adversity in Healthy Adults. Neuropsychopharmacology. 2010 Sep 29. [Epub ahead of print]

  31. Inflammation • HIV inflammation persists even when HIV is controlled. • Inflammation could be "cause" of co-morbidites and the "consequence" of  fatigued immune system (chronic activation) in setting of viral control. Having fixed the virus, we need to heal the immune system. • Obstacles to this healing, especially in women, may include depression, smoking, abuse and alcohol. • Emerging evidence suggests that addressing these factors may ↓ inflammation and ↓ morbidity and mortality from AIDS and non-AIDS Deeks SG. HIV infection, antiretroviral treatment, ageing, and non-AIDS related morbidity. BMJ 2009; 338:a3172

  32. Desai S, Cohen M, 2012

  33. Non AIDS disease is influenced by HIV, treatment, and behaviors and conditions associated with HIV infection Depression Abuse Alcohol Smoking Trad Gender Roles Justice, A. VACS. 2009

  34. Age CD4 Viral Load AIDS defining illnesses Hgb Renal function Liver function Chronic hep B and Hep C Diagnoses of alcohol and drug abuse VACS Risk Index Justice AC, et al. Towards a combined prognostic index for survival in HIV ifnection:the role of ‘nonHIV’ biomarkers. HIV Med 2009;11(2):143-151

  35. Proposed Women’s Prognostic Index • Age • CD4 • Viral Load • AIDS defining illnesses • Hgb (anemia) • Renal function • Liver function • Chronic hep B and HCV • BMI • Depressive symptoms • Traditional Gender Role behaviors • Gender based violence/Abuse • Smoking • Alcohol • Community level variance

  36. Women’s Index • Validate in different geographic settings • Prioritize modifiable factors/behaviors • Tangible tool to assure that care is comprehensive and directed towards better outcomes • Potentially generalizable to men with HIV

  37. The Women’s Index/Scorecard:Clinical Applications • Women could have their own scorecard with their behaviors and lab values • Work with health providers to understand their disease and improve their prognosis (stop smoking, adhere to ART, colposcopy, reduce weight, treat HCV, treat depressive symptoms, identify and manage stress) • Monitor changes over time

  38. Increase empowerment and self efficacy • Develop peer led model of implementation • Distribution and explanation of use of scorecard • Assess efficacy • Patient satisfaction • Behavior changes • Outcomes

  39. Engage Providers Remind Providers of all that has to be addressed (multiple systems, secondary prevention, behaviors) Create real partnerships Encourage community level change Smoking cessation programs Address Gender Based Violence

  40. Policy Implications Thinking and planning beyond pills Highest quality comprehensive integrated care to address the complex needs throughout the life course of women with HIV Score card as a tool to increase patient ownership and provider engagement Where? Organizational requirements Reimbursement for comprehensive care services and venues (include community groups) Creating critical mass complemented by distributed specialized networks

  41. Big Picture Women with HIV are living longer but not living as well as they should. Socioeconomic inequality, lower health literacy, inadequate access to high-quality health care and high-risk environments that result from racial and sex biases are responsible Logistic support (clinic access, transportation, child care, housing) is basic and necessary

  42. Positive Agenda Care about women throughout the life course to better prevention & treatment Include women with HIV in addressing care issues Provide drug treatment, smoking cessation, mental health and trauma care Fund peer support to get women re-engaged in care when they drop out With this, we can and will do better

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