Cancer burden attributable to cigarette smoking among HIV-infected people in North America.

OBJECTIVE: With combination-antiretroviral therapy, HIV-infected individuals live longer with an elevated burden of cancer. Given the high prevalence of smoking among HIV-infected populations, we examined the risk of incident cancers attributable to ever smoking cigarettes. DESIGN: Observational cohort of HIV-infected participants with 270 136 person-years of follow-up in the North American AIDS Cohort Collaboration on Research and Design consortium. Among 52 441 participants, 2306 were diagnosed with cancer during 2000-2015. MAIN OUTCOME MEASURES: Estimated hazard ratios and population-attributable fractions (PAF) associated with ever cigarette smoking for all cancers combined, smoking-related cancers, and cancers that were not attributed to smoking. RESULTS: People with cancer were more frequently ever smokers (79%) compared with people without cancer (73%). Adjusting for demographic and clinical factors, cigarette smoking was associated with increased risk of cancer overall [hazard ratios = 1.33 (95% confidence interval: 1.18-1.49)]; smoking-related cancers [hazard ratios = 2.31 (1.80-2.98)]; lung cancer [hazard ratios = 17.80 (5.60-56.63)]; but not nonsmoking-related cancers [hazard ratios = 1.12 (0.98-1.28)]. Adjusted PAFs associated with ever cigarette smoking were as follows: all cancers combined, PAF = 19% (95% confidence interval: 13-25%); smoking-related cancers, PAF = 50% (39-59%); lung cancer, PAF = 94% (82-98%); and nonsmoking-related cancers, PAF = 9% (1-16%). CONCLUSION: Among HIV-infected persons, approximately one-fifth of all incident cancer, including half of smoking-related cancer, and 94% of lung cancer diagnoses could potentially be prevented by eliminating cigarette smoking. Cigarette smoking could contribute to some cancers that were classified as nonsmoking-related cancers in this report. Enhanced smoking cessation efforts targeted to HIV-infected individuals are needed.

Quality of life improvement in Latinas receiving combined substance use disorders and trauma-specific treatment: a cohort evaluation report.

BACKGROUND: This study evaluates the benefits of integrating behavioral health and trauma services for Latinas with a history drug use. Changes in quality of life (QOL) domains were documented after participation in a manualized intervention in a cohort of Latinas. METHODS: Participants were part of a prospective cohort study of 136 Latinas with co-occurring disorders (COD) who may have experienced trauma and receiving services in our outpatient treatment facility in Bayamón, Puerto Rico. The WHOQOL-BREF Spanish version was used to score physical, psychological, social, and environmental QOL domains, at intake and after six months. Sociodemographic variables, alcohol, drug use, mental health disorders, and severity of substance use disorders (as defined by the DSM-5) were also tabulated. Descriptive statistics and paired t test or the Wilcoxon signed-rank test were computed for comparison. RESULTS: A median age of 39 years was seen and with 76% high school education or higher degree. The majority were unemployed (95.9%). A diagnosis of severe cocaine use (51.4%) was present and almost half (49.5%) had three or more DSM-5 diagnoses. Mean QOL scores were higher at six months with statistically significant differences in each domain. Women with neurodevelopmental disorders and schizophrenia yielded higher mean QOL scores for each domain at six months except for the social domain. Women with polydrug use and women who reported exposure to trauma and depressive disorder experienced statistically significant increments in the physical, psychological and social domains in comparison to counterpart women. CONCLUSIONS: Significant and positive changes in QOL were found in each domain. Latinas who reported traumatic events had lower scores in the physical and psychological QOL domains. There was a high prevalence of diminished physical and mental functioning in Latinas with COD. The exposure to trauma and the lack of social support negatively affect treatment access and retention for Latinas.

Late HIV Testing in a Cohort of HIV-Infected Patients in Puerto Rico.

OBJECTIVE: Late HIV testing (LT), defined as receiving an AIDS diagnosis within a year of one's first positive HIV test, is associated with higher HIV transmission, lower HAART effectiveness, and worse outcomes. Latinos represent 36% of LT in the US, yet research concerning LT among HIV cases in Puerto Rico is scarce. METHODS: Multivariable logistic regression analysis was used to identify factors associated with LT, and a Cochran‒Armitage test was used to determine LT trends in an HIV-infected cohort followed at a clinic in Puerto Rico specialized in the management and treatment of HIV. RESULTS: From 2000 to 2011, 47% of eligible patients were late testers, with lower median CD4 counts (54 vs. 420 cells/mm3) and higher median HIV viral load counts (253,680 vs. 23,700 copies/mL) than non-LT patients. LT prevalence decreased significantly, from 47% in 2000 to 37% in 2011. In a mutually adjusted logistic regression model, males, older age at enrollment and past history of IDU significantly increased LT odds, whereas having a history of amphetamine use decreased LT odds. When the data were stratified by mode of transmission, it became apparent that only the category men who have sex with men (MSM) saw a significant reduction in the proportion of LT, falling from 67% in 2000 to 33% in 2011. CONCLUSION: These results suggest a gap in early HIV detection in Puerto Rico, a gap that decreased only among MSM. An evaluation of the manner in which current HIV-testing guidelines are implemented on the island is needed.

Impact of ASUMA Intervention on HIV Risk Behaviors among Puerto Rican Adolescents.

The purpose of this manuscript is to assess and compare HIV risk behaviors among early adolescents after a three-year pilot study. A total of 135 public and private junior high schools students completed the intervention protocol. A self-administered questionnaire was given at baseline and at the end of the third year (fourth measure). Descriptive and inferential analyses were performed using SPSS 20.0. About 60% of the students were 14 years old at the fourth measure. The proportion of students that did not report at least one HIV risk behavior at baseline and those that reported any risk behavior at the fourth measure was lower in the intervention group (45.0%) than in the control group (54.5%). The proportion of students that reported at least one HIV risk behavior at baseline and those that did not report any HIV risk behavior at the fourth measure was higher in the intervention group than in the control group (33.3% vs. 8.3%). The proportion of students engaging in HIV risk behaviors was higher in the control group than in the intervention group at the fourth measure, suggesting that A Supportive Model for HIV Risk Reduction in Early Adolescence (ASUMA) intervention might be a promising initiative to reduce adolescents' engagement in HIV risk behaviors.

Profile of HIV-Infected Hispanics with Pancytopenia.

Pancytopenia is seen in late HIV infection; it is associated with medical complications and with decreased survival. We determined the prevalence of pancytopenia at baseline in a cohort of HIV-positive Hispanics living in Puerto Rico, and compared their socio-demographic, immunological and clinical characteristics. A total of 1202 patients enrolled between 2000 and 2010 were included. They were grouped according to pancytopenia status, defined by having: platelets <150,000 µL, white cell count <4000 µL, and hemoglobin <12 g/dL (women) or <13 g/dL (men). Differences were evaluated using Student's t-test, Chi-square test and Kaplan-Meier method. The prevalence of pancytopenia was 8.7%. Patients with pancytopenia had lower BMI and lower CD4 count, as well as higher HIV viral load and higher proportions of unemployment, clinical AIDS and antiretroviral treatment (ART) use (p < 0.05). One-year mortality rate was significantly higher in patients with pancytopenia (18.1% vs. 5.1%, p < 0.001). When stratifying for ART this association persisted for patients who did not receive ART (41.4% vs. 5.2%, p < 0.001), but it was not seen in patients who received treatment (9.2% vs. 5.6%, p = 0.196). Pancytopenia was associated with elements of advanced stages of HIV. ART could reduce the mortality of HIV-patients with pancytopenia to levels comparable to patients without the disorders.

Late HIV Testing in a Cohort of HIV-Infected Patients in Puerto Rico.

OBJECTIVE: Late HIV testing (LT), defined as receiving an AIDS diagnosis within a year of one's first positive HIV test, is associated with higher HIV transmission, lower HAART effectiveness, and worse outcomes. Latinos represent 36% of LT in the US, yet research concerning LT among HIV cases in Puerto Rico is scarce. METHODS: Multivariable logistic regression analysis was used to identify factors associated with LT, and a Cochran‒Armitage test was used to determine LT trends in an HIV-infected cohort followed at a clinic in Puerto Rico specialized in the management and treatment of HIV. RESULTS: From 2000 to 2011, 47% of eligible patients were late testers, with lower median CD4 counts (54 vs. 420 cells/mm3) and higher median HIV viral load counts (253,680 vs. 23,700 copies/mL) than non-LT patients. LT prevalence decreased significantly, from 47% in 2000 to 37% in 2011. In a mutually adjusted logistic regression model, males, older age at enrollment and past history of IDU significantly increased LT odds, whereas having a history of amphetamine use decreased LT odds. When the data were stratified by mode of transmission, it became apparent that only the category men who have sex with men (MSM) saw a significant reduction in the proportion of LT, falling from 67% in 2000 to 33% in 2011. CONCLUSION: These results suggest a gap in early HIV detection in Puerto Rico, a gap that decreased only among MSM. An evaluation of the manner in which current HIV-testing guidelines are implemented on the island is needed.

Anemia in a cohort of HIV-infected Hispanics: prevalence, associated factors and impact on one-year mortality.

BACKGROUND: Anemia occurs frequently in HIV-infected patients and has been associated with an increased risk of death in this population. For Hispanic subjects, information describing this blood disorder during HIV is scarce. Therefore, the present study examined data from a cohort of HIV-positive Hispanics to determine the prevalence of anemia, identify its associated factors, and evaluate its relationship with one-year mortality. METHODS: This study included 1,486 patients who enrolled between January, 2000 and December, 2010 in an HIV-cohort in Bayamón, Puerto Rico. Data were collected through personal interviews and medical record abstractions. To determine the factors independently associated with anemia, a multivariable logistic regression model was used. Kaplan-Meier and Cox proportional hazards models were also performed to estimate survival time and to predict death risk. RESULTS: The prevalence of anemia at enrollment was 41.5%. Factors independently associated with increased odds of anemia were: unemployment (OR = 2.02; 95% CI 1.45-2.79), CD4 count <200 cells/µL (OR = 2.66; 95% CI 1.94-3.66), HIV viral load ≥100,000 copies/mL (OR = 1.94; 95% CI 1.36-2.78), white blood cell count <4,000 cells/µL (OR = 2.42; 95% CI 1.78-3.28) and having clinical AIDS (OR = 2.39; 95% CI 1.39-4.09). Overweight (OR = 0.43; 95% CI 0.32-0.59) and obese (OR = 0.44; 95% CI 0.29-0.67) BMI's were independently associated with reduced odds of anemia. Survival differed significantly by anemia status (log-rank test: p < 0.001). One-year mortality estimates were: 30.8%, 23.3%, 8.4% and 2.5%, for patients with severe, moderate, mild and no anemia, respectively. Having anemia at baseline was independently associated with an increased one-year mortality risk (severe anemia: HR = 9.06; 95% CI: 4.16-19.72; moderate anemia: HR = 6.51; 95% CI: 3.25-13.06; mild anemia: HR = 2.53; 95% CI: 1.35-4.74). CONCLUSIONS: A high prevalence of anemia at enrollment was observed in this cohort of HIV-infected Hispanics. Unemployment and several adverse prognostic features of HIV infection were independently associated with this blood disorder. Anemia resulted to be the strongest predictor of one-year mortality, evidencing a dose-response effect. Further investigations are needed to evaluate whether recovering from anemia is associated with longer survival, and to identify the types of anemia affecting this particular group of HIV patients.

HIV/AIDS in the Puerto Rican elderly: immunological changes between gender and body mass index.

PURPOSE: Human immunodeficiency virus (HIV) in the elderly population has serious repercussions. The elderly are underdiagnosed for HIV and the costs associated with their late-stage care represent a financial burden to the public health system. The purpose is to analyze various profiles among a cohort of elderly patients with HIV/AIDS. METHODS: This is a baseline cohort 60 years or older seen in the Retrovirus Research Center between January 2000 to December 2011. We present the profiles of our cohort stratified by gender and body mass index viewed as a covariate of interest. RESULTS: A total of 266 people (68% males and 32% females) seen at the Center were older than 60 years of age. Males were significantly more often overweight (p<.05). Females were significantly more underweight with chronic conditions (p<.05). Women had higher CD4 count and lower HIV viral loads (p<.05). Underweight elderly males were more heavily affected with the burden of HIV infection compared with women.

Toxoplasmic encephalitis in an AIDS cohort at Puerto Rico before and after highly active antiretroviral therapy (HAART).

Highly active antiretroviral therapy (HAART) significantly reduced the toxoplasmic encephalitis (TE) incidence in acquired immunodeficiency syndrome (AIDS) patients. The TE incidence and mortality were evaluated in an AIDS cohort followed in Puerto Rico before, during, and after HAART implementation in the Island. Of the 2,431 AIDS studied patients 10.9% had TE diagnosis, with an incidence density that decreased from 5.9/100 person-years to 1.1/100 person-years after HAART. Cox proportional hazard analysis showed substantial mortality reduction among TE cases who received HAART. No mortality reduction was seen in those cases who received TE prophylaxis. Although this study shows a TE incidence and mortality reduction in the AIDS cohort after HAART, the incidence was higher than those reported in the United States AIDS patients. Poor TE prophylaxis compliance might explain the lack of impact of this intervention. Strengthening the diagnostic and opportune TE diagnosis and prompt initiation of HAART in susceptible patients is important to control this opportunistic infection.

Changes in developmental factors and HIV risk behaviors among early adolescents in Puerto Rico.

INTRODUCTION: Teenagers are the fastest growing group of newly HIV-infected persons. Consequently, a support model for HIV risk reduction was designed and implemented for early adolescents in Puerto Rico. OBJECTIVE: The purpose of this article is to assess changes in developmental factors and HIV risk behaviors among early adolescents after three years of follow-up of an intervention and a non-intervention group. METHODS: This prospective cohort study followed 135 early adolescents who were enrolled in the ASUMA (A Supportive Model for HIV Risk Reduction in Early Adolescents) Project. The study was performed in two public and two private junior schools. Baseline and three follow-up self-administered questionnaires were given. We examined sociodemographic factors, HIV risk behavior and developmental factors. RESULTS: 48% were in the intervention group and 51.1% were controls. Most adolescents were aged 12 years; 47.4% were males; 75.6% reported not having risk behaviors and 24.4% reported having risk behaviors at anytime in their lifespan. A significant decrease in the HIV risk behaviors median was observed among the intervention group (P < .05), while a nonsignificant increase was found among adolescents in the control group. At the end of the implementation phase, positive improvement in the developmental factors were observed in the intervention group (P < .05). CONCLUSIONS: Our study suggests that the ASUMA project curriculum had a positive effect on developmental factors and HIV risk behaviors, as proposed in our conceptual framework. Also, this study illustrates the importance of the creation of culturally appropriate instruments and interventions to reach the goal of HIV/AIDS reduction.

Profile of Puerto Rican HIV/AIDS patients with early and non-early initiation of injection drug use.

BACKGROUND: Early initiation of injection drug use (IDU) increases the risk of HIV infection. METHODS: We compare the sociodemographic, psychosocial, and clinical profiles of HIV-positive IDU patients according to the age at which IDU was initiated. This is a cross-sectional study of 1308 patients seen from 1992 through 2005. We compared the profile of patients with early (age < 13 years) vs non-early (age > 13 years) initiation of IDU. The Fisher and chi2 differences in proportions were performed to assess difference among study groups with earlier IDU. The Mantel-Haenszel test was used to calculate the odds ratio. The Kaplan-Meier and log rank tests were used to assess the median survival. Differences were considered significant at alpha = .05. RESULTS: Early initiation of IDU was reported in 11% of our sample. The early initiation group was more likely to smoke tobacco, use alcohol, attempt suicide, have a history of incarceration, have economic problems, and have episodes of anxiety, confusion, depression, excitation, impulsivity, and violence (P < .05). The general survival time of patients was 36.9 months (95% confidence interval 31.9-42.0). A higher prevalence of candidial esophagitis and Pneumocystis jirovecii pneumonia and a lower prevalence of hepatitis C virus coinfection were seen in the early initiation group (P < .05). No differences in mortality, use of antiretroviral therapy, or CD4 T-cell count were seen. CONCLUSIONS: Differences in terms of lifestyle, stress factors, and history of psychological events were seen in the group of patients with early initiation of IDU seen in our facilities. Differences in the clinical scenario were documented.