Appropriateness of antiretroviral therapy in clients of an HIV/AIDS case management organization.

We sought to assess appropriateness of antiretroviral therapy (ART) reported by clients of an HIV/AIDS case management organization and identify variables associated with appropriate ART receipt. A total of 295 such clients were mailed a survey asking them to identify antiretroviral medications they were taking. Of them 220 (75%) returned surveys; 201 (93%) were taking antiretrovirals. Of these, 159 were on appropriate and 36 on inappropriate ART, as determined by guidelines created by the CDC, the International AIDS Society (USA Panel), and the Panel on Clinical Practices for Treatment of HIV Infection. In unadjusted analyses, age, sex, race, sexual orientation, history of injection drug use, history of sexual risk, and HIV knowledge were associated (p< or =0.10) with appropriate ART and entered into one of two logistic regression models. The first model indicated that women (p=0.003) and heterosexuals (p=0.001) were less likely to receive appropriate ART than men and gay/bisexuals (and variables interacted, p=0.001). HIV knowledge--a proxy indicator determined by self-report of a CD4 cell count and viral load--was added to variables retained in first model to create a second model. Only sexual orientation was retained in this second model (p=0.02, in the same direction as in the first model), and those with less versus more HIV knowledge (p=0.04) were found to be less likely to receive appropriate ART (and variables interacted, p=0.04). Findings suggest that heterosexual men are less likely than women who, in turn, are less likely than gay/bisexual men to receive appropriate ART. HIV-related knowledge appears to increase likelihood of receiving appropriate ART and it attenuates the effect of sex.

Balancing disfigurement and fear of disease progression: Patient perceptions of HIV body fat redistribution.

This study was conducted to identify and describe the perceived morphologic changes of body fat redistribution and related distress among persons taking combination antiretroviral therapy. Six focus group interviews were conducted in four different US cities with men and women (n = 58) who reported antiretroviral-related symptoms of body fat loss and/or gain. Interview data were audiotaped, transcribed verbatim and systematically analysed using inductive techniques. Physical discomfort and impairment and psychological and social distress were reported across sex, sexual orientation and geographic subgroups. While participants acknowledged that antiretroviral drugs were keeping them alive, there was tension between the desire for life-sustaining treatment and optimal quality of life. Some participants engaged in harmful heath behaviours in an attempt to control bodily changes (e.g. non-adherence to antiretroviral regimen). Participants feared that fat loss represented disease progression and worried that visible changes would lead to unintentional disclosure of their HIV status. Although a potential source of support, healthcare providers were commonly perceived as ignoring and, in so doing, discrediting patient distress. Participants recognised the limitations of current lipodystrophy treatment options, yet a cure for the syndrome seemed less important to them in the short term than simply being listened to and the powerful, but oblique sources of distress addressed.

Two approaches to measuring quality of life in the HIV/AIDS population: HAT-QoL and MOS-HIV.

OBJECTIVES: Reduce the number of HIV/AIDS-Targeted Quality of Life (HAT-QoL) items, assess psychometric performance of the shortened HAT-QoL, and compare psychometric performance of HAT-QoL to that of Medical Outcomes study HIV Health Survey (MOS-HIV). DESIGN/SUBJECTS: Convenience sample of 215 cross-sectionally studied seropositive individuals. METHODS: Subjects completed the HAT-QoL, MOS-HIV, and sociodemographic and disease-specific questions. HAT-QoL and MOS-HIV responses were entered, separately, into principal components analysis (PCA). Results from PCA, internal consistency and correlation assessments were used to aid the item removal process. Dimension characteristics (e.g., score distributions, internal consistency, scaling success rates, intercorrelations, construct validity) were evaluated. RESULTS: PCA of subjects' (80% male; 45% white; 62% gay/bisexual) responses revealed nine previously identified HAT-QoL dimensions. The measure was shortened by removing 12 items. Two HAT-QoL dimensions (HIV mastery and provider trust) had ceiling effects. All internal consistency coefficients were > 0.80, except those for sexual function (0.57) and medication concerns (0.57). HAT-QoL scaling success rates were > 90% for 7 of 9 dimensions, and a majority of dimensions showed minimal to low intercorrelations. Validity assessments indicated consistent, expected relationships (p < or = 0.05) for all dimensions except the medication concerns and provider trust dimensions. PCA indicated five MOS-HIV factors. Six of the 11 previously defined MOS-HIV dimensions--physical, role, social, and cognitive function, pain, and health transition--had substantial ceiling effects. MOS-HIV scaling success rates were > 90% for only 2 out of 8 evaluable dimensions; three dimensions had very low (40-73%) scaling success rates. Most MOS-HIV dimensions were moderately-to-highly intercorrelated. Validity assessments indicated consistent, expected relationships for all MOS-HIV dimensions. CONCLUSIONS: Six dimensions of the shortened HAT-QoL instrument (overall function, disclosure worries, health worries, financial worries, HIV mastery, and life satisfaction) exhibited good psychometric properties, including limited ceiling effects, low dimension intercorrelations, high internal consistency, and evidence for construct validity. All multi-item MOS-HIV dimensions had high internal consistency and all dimensions revealed consistent evidence for construct validity.

Sexual abuse of boys: definition, prevalence, correlates, sequelae, and management.

OBJECTIVE: To clarify the definition of sexual abuse of boys, update estimates of its prevalence, and explore critically its reported correlates, sequelae, and management. DATA SOURCES: Studies from 1985 to 1997 were identified using OVID-MEDLINE and OVID-CINAHL. The search terms used were sexual abuse, sexual victimization, and sexual assault. Constraints applied included English language, human male subjects, age younger than 19 years, and North American samples. STUDY SELECTION: Publications were included for review if they appeared in peer-reviewed journals; had clear research designs; reported results for at least 20 male subjects; and were not reviews, perspectives, theoretical treatises, editorials, or letters. DATA EXTRACTION: Study types and sampling methods were categorized using well-established definitions. Preference was given to studies with large samples, with case-control or cohort designs, and/or with adjustment for effect modifiers or confounders. DATA SYNTHESIS: We identified 166 studies representing 149 sexual abuse samples. Studies were methodologically limited and definitions of sexual abuse varied widely. Prevalence estimates varied widely (by definition used and population studied), ranging from 4% to 76%. Boys at highest risk were younger than 13 years, nonwhite, of low socioeconomic status, and not living with their fathers. Perpetrators tended to be known but unrelated males. Abuse frequently occurred outside the home, involved penetration, and occurred more than once. Sequelae included psychological distress, substance abuse, and sexually related problems. Evaluation of management strategies was limited. CONCLUSIONS: Sexual abuse of boys appears to be common, underreported, underrecognized, and undertreated. Future study requires clearer definitions of abuse, improved sampling, more rigorous data collection, more sophisticated data analyses, and better assessment of management and treatment strategies. Regardless, health care professionals should be more aware of and sensitive to the possibility of sexual abuse in their male patients.

A new HIV/AIDS-targeted quality of life (HAT-QoL) instrument: development, reliability, and validity.

OBJECTIVES: The objectives of this study were to identify quality-of-life concerns, as reported by human immunodeficiency virus (HIV) seropositive individuals, and to develop a measure to assess these concerns. METHODS: The HIV/acquired immunodeficiency syndrome (AIDS)-targeted measure was developed in two linked studies. In study one, group discussions with 42 HIV seropositive individuals were used to generate item content for the new measure. In study two, 201 HIV seropositive individuals were cross-sectionally studied to identify dimensions and to reduce the number of items of the quality of life questionnaire resulting from study one. RESULTS: Study one subjects (76% male; 66% white; 55% gay/bisexual) identified concerns captured by 76 items. Factor analysis indicated that responses of study two subjects (78% male; 42% white; 55% gay/bisexual) could be summarized by nine dimensions. Overall function, sexual function, disclosure worries, health worries, financial worries, HIV mastery, life satisfaction, medication concerns, and provider trust dimensions were refined by removing items using methods to maximize internal consistency and to minimize item redundancy. No substantial ceiling/floor effects existed, except for the provider trust dimension (43% received the highest score possible). All internal consistency coefficients were > or = 0.70, except those for the HIV mastery (0.57) and medication concerns (0.51) dimensions, as well as the sexual function dimension (0.56) in the non-AIDS subsample. Multitrait/multiitem assessment indicated scaling success rates that were high (> or = 91%) for eight of nine dimensions (HIV mastery revealed a lower but modest success rate of 79%). Validity assessments, using self-reported HIV disease severity and sociodemographic variables, indicated expected relationships for all dimensions. CONCLUSIONS: Five dimensions of the new HIV/AIDS-targeted quality of life instrument (overall function, disclosure worries, health worries, financial worries, and life satisfaction) exhibited good psychometric properties, including low ceiling/floor effects, good internal consistency, and evidence for construct validity.

A short, psychiatric, case-finding measure for HIV seropositive outpatients: performance characteristics of the 5-item mental health subscale of the SF-20 in a male, seropositive sample.

OBJECTIVES: The author assesses performance characteristics of the 5-item mental health scale (MHI-5) of the Medical Outcomes Study Short Form Health Survey when used as a psychiatric case-finding measure for human immunodeficiency virus (HIV) seropositive outpatients. METHODS: Ninety-five HIV seropositive outpatients from two primary care practices were recruited and cross-sectionally studied. All subjects completed the MHI-5. Standardized Clinical Interview for DSM-III-R (SCID-NP-HIV) was used as the gold standard in assessing Axis I psychiatric disorders in the previous 6 months. RESULTS: Thirty-three of 95 (35%) subjects had Axis I disorders (Axis I): 18 of 33 (55%) had a diagnosis of major depression (MD); 15 of 33 (45%) had another diagnosis (AD). Areas under receiver operator characteristic (ROC) curves were 0.76 (95% confidence interval [CI], 0.65, 0.87; Axis I), 0.84 (95% CI, 0.74, 0.94; MD), and 0.55 (95% CI, 0.38, 0.72; AD). The area under the MD curve was significantly greater than that for the AD curve (P = 0.0017). The optimal subscale score cut-off point on the MD curve was 52. Test characteristics for this cut-off point were: sensitivity, 83%; specificity, 65%; positive predictive value, 36%; negative predictive value, 94%; likelihood ratio for a positive test, 2.37; and likelihood ratio for a negative test, 0.26. CONCLUSIONS: The MHI-5 is the first short psychiatric case-finding measure for which performance characteristics have been reported for HIV seropositive outpatients. Test characteristics suggest that it may be a useful case-finding measure for these patients. A positive finding may indicate a diagnosis of recent major depression.

Performance of a new, HIV/AIDS-targeted quality of life (HAT-QoL) instrument in asymptomatic seropositive individuals.

OBJECTIVE: To evaluate the psychometric performance of a new human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS)-targeted quality of life (QoL) instrument in asymptomatic HIV-seropositive individuals. METHODS: 201 urban and rural, HIV-seropositive subjects were recruited to complete a 76-item pilot QoL measure developed using content provided in group process by seropositive individuals. Questionnaire responses from the full sample (n = 201) were used to identify dimensions and to reduce the number of items to 42. The responses to the retained items were then analysed for the asymptomatic subsample (n = 106). RESULTS: 9 multi-item dimensions were identified: overall function (OF), sexual function (SF), disclosure worries (DW), health worries (HW), financial worries (FW), HIV mastery (HM), life satisfaction (LS), medication concerns (MC) and provider trust (PT). The responses by asymptomatic subjects (74% male, 64% non-White and 63% homosexual/bisexual) revealed no substantial floor or ceiling effects, except for the PT dimension (where 44% were found to have scored the highest score). The internal consistency coefficients (Cronbach's alphas) were between 0.80 and 0.89 for six dimensions. The coefficients were lower for the SF (0.52), HM (0.67) and MC (0.48) dimensions. Construct validity assessments, using self-reported HIV disease-severity and sociodemographic variables, revealed some significant relationships (p < or = 0.05) for all dimensions except SF, MC and PT. CONCLUSIONS: The results suggested that five dimensions (OF, DW, HW, FW and LS) from the new instrument have good psychometric properties for asymptomatic HIV-seropositive individuals. These dimensions may be useful in the study of asymptomatic, seropositive individuals' QoL. Four dimensions (SF, HM, MC and PS) require additional refinement for this subpopulation.

Association between a history of childhood sexual abuse and subsequent, adolescent psychoactive substance use disorder in a sample of HIV seropositive men.

PURPOSE: Examine whether an association exists between having a sexual abuse history and having a psychoactive substance use disorder (PSUD) history in a population of HIV seropositive men. METHODS: Survey study of 95 HIV seropositive men. Sociodemographic and sexual abuse histories obtained before administration of the Standardized Clinical Interview for DSM-III-R (SCID-NP-HIV)-used to identify PSUD. RESULTS: Nineteen (20%) subjects had sexual abuse histories. Sexual abuse occurred early (mean age: 8.1 years). Ten (53%) subjects reported oral (n = 4) and/or anal (n = 9) penetration by perpetrator. Comparing men with histories of sexual abuse to men without, the odds ratio (OR) for subsequent injection drug use was 5.4 (1.5, 19.6), and for subsequent early (before age 20) injection drug use was 21.6 (3.4, 224.5). Adjusted ORs were 2.4 (0.55, 10.6) and 12.2 (1.7, 90.3), respectively. CONCLUSIONS: In this sample of HIV seropositive men, an association between having been sexually abused and subsequently initiating injection drug use during adolescence exists. Future studies that more rigorously evaluate the possible causal nature of this association are indicated.

Human immunodeficiency virus (HIV) infection and quality of life: the potential impact of Axis I psychiatric disorders in a sample of 95 HIV seropositive men.

OBJECTIVE: The purpose of this study is to assess whether Axis I psychiatric disorders exert effects on function and well-being independent of human immunodeficiency virus (HIV)-related disease progression. METHODS: A convenience sample of 95 HIV seropositive individuals completed the Medical Outcomes Study Short Form Health Survey (SF-20). The Standardized Clinical Interview for DSM-III-R (SCID-NP-HIV) was used to screen subjects for Axis I psychiatric disorders in the previous 6 months. HIV-related disease severity was defined for each subject using the 1993 revised Centers for Disease Control (CDC) Classification System. RESULTS: Thirty-seven (39%) subjects had asymptomatic HIV disease and 58 (61%) had symptomatic disease. Thirty-three (35%) subjects had Axis I disorders in the previous 6 months. After controlling for HIV-related disease severity, psychiatric disorders were independently associated with substantive decrements in the mental health and health perceptions dimension scores (beta-coefficients were approximately -18.0 for both dimensions; p < or = 0.01). Axis I disorders were also associated with decrements in the social functioning dimension at a p value that approached significance (p = 0.04). CONCLUSIONS: In HIV seropositive individuals, the presence of an Axis I psychiatric disorder in the previous 6 months is associated with diminished scores in multiple areas of functioning and well-being, independent of HIV-related disease progression. Axis I disorders, therefore, appear to impact quality of life. These findings, in part, suggest that the SF-20 (the mental health subscale, in particular) may have utility as a screening tool for the presence of a recent Axis I diagnosis.