Expired CME Article

Minorities, the Poor, and Survivors of Abuse: HIV-Infected Patients in the US Deep South

Authors: Brian Wells Pence, PhD, MPH, Susan Reif, PhD, Kathryn Whetten, PhD, MPH, Jane Leserman, PhD, Dalene Stangl, PhD, Marvin Swartz, MD, Nathan Thielman, MD, MPH, Michael J. Mugavero, MD, MHSc

Abstract

Background: The HIV/AIDS epidemic in the U.S. South is undergoing a marked shift toward a greater proportion of new HIV/AIDS cases in women, African-Americans, and through heterosexual transmission.


Methods: Using consecutive sampling, 611 participants were interviewed from eight Infectious Diseases clinics in five southeastern states in 2001 to 2002.


Results: Sixty four percent of participants were African-American, 31% were female, and 43% acquired HIV through heterosexual sex; 25% had private health insurance. Eighty-one percent were on antiretroviral therapy, and 46% had HIV RNA viral loads (VL) <400. Women and racial/ethnic minorities were less likely to be on antiretrovirals and to have VL <400. Probable psychiatric disorders (54%) and history of childhood sexual (30%) and physical abuse (21%) were common.


Conclusions: Prevention and care systems need to address the HIV epidemic’s shift into poor, minority, and female populations. High levels of trauma and probable psychiatric disorders indicate a need to assess for and address these conditions in HIV clinical care.


Key Points


* HIV, both nationally and particularly in the US South, is increasingly affecting minorities, women, the poor, and those living in rural areas, and is increasingly transmitted through heterosexual intercourse.


* Mental illness, substance use, and history of psychosocial trauma are common comorbidities of HIV-infected patients: three out of four patients meet criteria for at least one of the three, with overlap common.


* These psychiatric comorbidities have been linked to worse clinical outcomes for HIV-positive individuals, suggesting that significant clinical benefit could be achieved by routinely integrating mental health assessment and related services into HIV clinical care.

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References

1. “Deep South”. Merriam Webster’s Collegiate Dictionary, 11th ed. Springfield, MA, Merriam-Webster, 2005.
 
2. Centers for Disease Control and Prevention (CDC). HIV/AIDS Surveillance Report, Vol. 13 (2001). Atlanta, GA, CDC, 2002.
 
3. Centers for Disease Control and Prevention (CDC). HIV/AIDS Surveillance Report, Vol. 17 (2005). Atlanta, GA, CDC, 2006.
 
4. Kaiser Family Foundation. State Health Facts. Available at: http://www.statehealthfacts.org. Accessed February 2, 2007.
 
5. Karon JM, Fleming PL, Steketee RW, De Cock KM. HIV in the United States at the turn of the century: an epidemic in transition. Am J Public Health 2001;91:1060–1068.
 
6. Centers for Disease Control and Prevention (CDC). HIV Prevention Strategic Plan through 2005. CDC. Available at: http://www.cdc.gov/hiv/partners/psp.htm. Accessed April 23, 2006.
 
7. Reif S, Geonnotti KL, Whetten K. HIV Infection and AIDS in the deep south. Am J Public Health2006;96:970–973.
 
8. Ricketts T: Rural Health in the United States. New York, Oxford University Press, 1999.
 
9. Bing EG, Burnam MA, Longshore D, et al. Psychiatric disorders and drug use among human immunodeficiency virus-infected adults in the United States. Arch Gen Psychiatry 2001;58:721–728.
 
10. Whetten-Goldstein K, Nguyen TQ: “You’re the First One I’ve Told”: New Faces of HIV in the South. New Brunswick, NJ, Rutgers University Press, 2002.
 
11. Wyatt GE, Myers HF, Loeb TB. Women, trauma, and HIV: an overview. AIDS Behav 2004;8:401–403.
 
12. Mugavero M, Ostermann J, Whetten K, et al. Barriers to antiretroviral adherence: the importance of depression, abuse, and other traumatic events. AIDS Patient Care STDS 2006;20:418–428.
 
13. Parienti JJ, Massari V, Descamps D, et al. Predictors of virologic failure and resistance in HIV-infected patients treated with nevirapine- or efavirenz-based antiretroviral therapy. Clin Infect Dis2004;38:1311–1316.
 
14. Pence BW, Miller WC, Gaynes BN, Eron JJ Jr. Psychiatric illness and virologic response in patients initiating highly active antiretroviral therapy. J Acquir Immune Defic Syndr 2006;Published ahead of print.
 
15. Hamburger ME, Moore J, Koenig LJ, et al. Persistence of inconsistent condom use: relation to abuse history and HIV serostatus. AIDS Behav 2004;8:333–344.
 
16. Kelly JA, Murphy DA, Bahr GR, et al. Factors associated with severity of depression and high-risk sexual behavior among persons diagnosed with human immunodeficiency virus (HIV) infection. Health Psychol 1993;12:215–219.
 
17. Whetten K, Leserman J, Whetten R, et al. Exploring lack of trust in care providers and the government as a barrier to health service use. Am J Public Health 2006;96:716–721.
 
18. American Psychological Association. The Behavioral Health Care Needs of Rural Women. The Report of the Rural Women’s Work Group of the Rural Task Force of the American Psychological Association and the American Psychological Association’s Committee on Rural Health. Available at:http://www.apa.org/rural/ruralwomen.pdf. Accessed August 31, 2006.
 
19. Fox J, Merwin E, Blank M. De facto mental health services in the rural south. J Health Care Poor Underserved 1995;6:434–468.
 
20. Burnam MA, Bing EG, Morton SC, et al. Use of mental health and substance abuse treatment services among adults with HIV in the United States. Arch Gen Psychiatry 2001;58:729–736.
 
21. Taylor SL, Burnam MA, Sherbourne C, et al. The relationship between type of mental health provider and met and unmet mental health needs in a nationally representative sample of HIV-positive patients. J Behav Health Serv Res 2004;31:149–163.
 
22. Population Division, U.S. Census Bureau. Table 1: Annual Estimates of the Population of Metropolitan and Micropolitan Statistical Areas: April 1, 2000 to July 1, 2005 (CBSA-EST2005-01). Available at: http://www.census.gov/population/www/estimates/Estimates%20pages_final.html. Accessed September 10, 2006.
 
23. Pfeiffer E. A short portable mental status questionnaire for the assessment of organic brain deficit in elderly patients. J Am Geriatr Soc 1975;23:433–441.
 
24. Derogatis LR, Melisaratos N. The Brief Symptom Inventory: an introductory report. Psychol Med1983;13:595–605.
 
25. Derogatis LR: Brief Symptoms Inventory (BSI): Administration, Scoring, and Procedures Manual. Minneapolis, MN, NCS Pearson, Inc, 1993.
 
26. Orlando M, Burnam MA, Beckman R, et al. Re-estimating the prevalence of psychiatric disorders in a nationally representative sample of persons receiving care for HIV: results from the HIV Cost and Services Utilization Study. Int J Methods Psychiatr Res 2002;11:75–82.
 
27. Pence BW, Miller WC, Whetten K, et al. Prevalence of DSM-IV-defined mood, anxiety, and substance use disorders in an HIV clinic in the Southeastern United States. J Acquir Immune Defic Syndr 2006;42:298–306.
 
28. McLellan AT, Kushner H, Metzger D, et al. The Fifth Edition of the Addiction Severity Index. J Subst Abuse Treat 1992;9:199–213.
 
29. Blanchard EB, Jones-Alexander J, Buckley TC, Forneris CA. Psychometric properties of the PTSD Checklist (PCL). Behav Res Ther 1996;34:669–673.
 
30. Leserman J, Whetten K, Lowe K, et al. How trauma, recent stressful events, and PTSD affect functional health status and health utilization in HIV-infected patients in the south. Available at:http://www.psychosomaticmedicine.org/cgi/content/full/67/3/500Psychosom Med 2005; 67:500–507.
 
31. 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) Study. Am J Prev Med 1998;14:245–258.
 
32. Hillis SD, Anda RF, Felitti VJ, Marchbanks PA. Adverse childhood experiences and sexual risk behaviors in women: a retrospective cohort study. Fam Plann Perspect 2001;33:206–211.
 
33. Panel on Clinical Practices for Treatment of HIV Infection. Guidelines for the Use of Antiretroviral Agents in HIV-Infected Adults and Adolescents, August 13, 2001: Department of Health and Human Services (DHHS); 2001.
 
34. Centers for Disease Control and Prevention (CDC). HIV/AIDS Surveillance Report, Vol. 14 (2002). Atlanta, GA, CDC, 2003.
 
35. Morrill R, Cromartie J, Hart LG. Metropolitan, urban, and rural commuting areas: toward a better depiction of the US Settlement System. Urban Geography 1999;20:727–748.
 
36. Alabama Department of Public Health. HIV/AIDS Slides 2005. Available at:http://www.adph.org/aids/HIVAIDS%20slides%202005.pdf. Accessed August 21, 2006, 2006.
 
37. Louisiana Department of Health and Hospitals. Louisiana HIV/AIDS annual report and epidemiological profile, 2002. Available at: http://www.dhh.louisiana.gov/offices/publications/pubs-264/2002%20HIV%20AIDS%20Annual%20Report.pdf. Accessed August 21, 2006.
 
38. Mississipi STD/HIV Bureau. Email communication regarding HIV/AIDS epidemiology in 2002 in Mississippi; 2006.
 
39. North Carolina Department of Health and Human Services HIV/STD Prevention and Care Branch. 2005 HIV/STD Surveillance Report. Available at: http://www.epi.state.nc.us/epi/hiv/pdf/std05rpt.pdf. Accessed August 21, 2006.
 
40. South Carolina Department of Health and Environmental Control. STD/HIV Division Surveillance Report, December 31, 2002. Available at: http://www.dhec.sc.gov/health/disease/stdhiv/docs/dec.pdf. Accessed August 21, 2006.
 
41. Gebo KA, Fleishman JA, Conviser R, et al. Racial and gender disparities in receipt of highly active antiretroviral therapy persist in a multistate sample of HIV patients in 2001. J Acquir Immune Defic Syndr 2005;38:96–103.
 
42. Palacio H, Kahn JG, Richards TA, Morin SF. Effect of race and/or ethnicity in use of antiretrovirals and prophylaxis for opportunistic infection: a review of the literature. Public Health Rep 2002; 117:233–251.
 
43. Briere J, Elliott DM. Prevalence and psychological sequelae of self-reported childhood physical and sexual abuse in a general population sample of men and women. Child Abuse Negl 2003;27:1205–1222.
 
44. Cohen M, Deamant C, Barkan S, et al. Domestic violence and childhood sexual abuse in HIV-infected women and women at risk for HIV. Am J Public Health 2000;90:560–565.
 
45. Wyatt GE, Myers HF, Williams JK, et al. Does a history of trauma contribute to HIV risk for women of color? Implications for prevention and policy. Am J Public Health 2002;92:660–665.
 
46. Regier DA, Boyd JH, Burke JD Jr et al. One-month prevalence of mental disorders in the United States, based on five epidemiologic catchment area sites. Arch Gen Psychiatry 1988;45:977–986.
 
47. Avants SK, Warburton LA, Hawkins KA, Margolin A. Continuation of high-risk behavior by HIV-positive drug users: treatment implications. J Subst Abuse Treat 2000;19:15–22.
 
48. Leserman J. HIV disease progression: depression, stress, and possible mechanisms. Biol Psychiatry 2003;54:295–306.
 
49. Ickovics JR, Hamburger ME, Vlahov D, et al. Mortality, CD4 cell count decline, and depressive symptoms among HIV-seropositive women: longitudinal analysis from the HIV Epidemiology Research Study. JAMA 2001;285:1466–1474.
 
50. Pence BW, Gaynes BN, Whetten K, et al. Validation of a brief screening instrument for substance abuse and mental illness in HIV-positive patients. J Acquir Immune Defic Syndr 2005;40:434–444.
 
51. Lyketsos CG, Fishman M, Hutton H, et al. The effectiveness of psychiatric treatment for HIV-infected patients. Psychosomatics 1997;38:423–432.
 
52. Whetten K, Reif S, Ostermann J, et al. Improving health outcomes among individuals with HIV, mental illness, and substance use disorders in the Southeast. AIDS Care 2006;18:S18–S26.
 
53. Sikkema KJ, Hansen NB, Kochman A, et al.: Outcomes from a group intervention for coping with HIV/AIDS and childhood sexual abuse: reductions in traumatic stress. AIDS Behav 2006.
 
54. Sikkema KJ, Hansen NB, Tarakeshwar N, et al. The clinical significance of change in trauma-related symptoms following a pilot group intervention for coping with HIV-AIDS and childhood sexual trauma.AIDS Behav 2004;8:277–291.
 
55. Wyatt GE, Longshore D, Chin D, et al. The efficacy of an integrated risk reduction intervention for HIV-positive women with child sexual abuse histories. AIDS Behav 2004;8:453–462.