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Prevalence and validation studies rely on imperfect reference standard (RS) diagnostic instruments that can bias prevalence and test characteristic estimates. The authors illustrate 2 methods to account for RS misclassification. Latent class analysis (LCA) combines information from multiple imperfect measures of an unmeasurable latent condition to estimate sensitivity (Se) and specificity (Sp) of each measure. With simple algebraic sensitivity analysis (SA), one uses researcher-specified RS misclassification rates to correct prevalence and test characteristic estimates and can succinctly summarize a range of scenarios with Monte Carlo simulation. The authors applied LCA to a validation study of a new substance use disorder (SUD) screener and a larger prevalence study. With a traditional validation study analysis in which an error-free RS (Structured Clinical Interview for DSM-IV Axis I Disorders [SCID]; M. H. First, R. L. Spitzer, M. Gibbon, & J. Williams, 1990) is assumed, the authors estimated the screener had 86% Se and 75% Sp. Validation study estimates from LCA were 91% Se, 81% Sp (screener), 73% Se, and 98% Sp (SCID). SA in the prevalence study suggested the prevalence of SUD was underestimated by 22% because SCID was assumed to be error-free. LCA and SA can assist investigators in relaxing the unrealistic assumption of perfect RSs in reporting prevalence and validation study results. (Contains 3 tables.)

Co-occurrence of HIV and substance abuse is associated with poor outcomes for HIV-related health and substance use. Integration of substance use and medical care holds promise for HIV patients, yet few integrated treatment models have been reported. Most of the reported models lack data on treatment outcomes in diverse settings. This study examined the substance use outcomes of an integrated treatment model for patients with both HIV and substance use at three different clinics. Sites differed by type and degree of integration, with one integrated academic medical center, one co-located academic medical center, and one co-located community health center. Participants (n = 286) received integrated substance use and HIV treatment for 12 months and were interviewed at 6-month intervals. We used linear generalized estimating equation regression analysis to examine changes in Addiction Severity Index (ASI) alcohol and drug severity scores. To test whether our treatment was differentially effective across sites, we compared a full model including site by time point interaction terms to a reduced model including only site fixed effects. Alcohol severity scores decreased significantly at 6 and 12 months. Drug severity scores decreased significantly at 12 months. Once baseline severity variation was incorporated into the model, there was no evidence of variation in alcohol or drug score changes by site. Substance use outcomes did not differ by age, gender, income, or race. This integrated treatment model offers an option for treating diverse patients with HIV and substance use in a variety of clinic settings. Studies with control groups are needed to confirm these findings. DOI: 10.1089/apc.2010.0073

Fatigue is one of the most common and debilitating complaints of HIV-positive individuals, potentially leading to important functional limitations. We recruited 128 HIV-positive individuals (fatigued and nonfatigued) between March 2005 and May 2006; 66% were male, 66% were African American, 45% had greater than a high school education, 67% were unemployed, and ages ranged from 26-66 (median, 44). Every 3 months for 15 months, participants completed a 56-item self-report fatigue scale developed and validated by the authors. Participants were classified as fatigued or not fatigued at each assessment and received scores for fatigue intensity and impact of fatigue on functioning. We used linear mixed-effects models to assess longitudinal variation in fatigue scores and generalized estimating equations for binary outcomes to model predictors of fatigue remission among those fatigued at baseline. At baseline, 88% of the sample was fatigued. Fatigue measures were highly correlated across time points (p 0.63-0.85 [intensity], 0.63-0.80 [functioning]) and showed no evidence of overall improvement, deterioration, or convergence over time. Predictors of lower fatigue scores included higher income, employment, longer time since HIV diagnosis, and antiretroviral therapy use. Those employed at baseline were likely to show improvements in fatigue while those unemployed were not. Of those fatigued at baseline, 11% experienced remission during follow-up; remission was associated with Caucasian race and employment. In summary, fatigue intensity and related functional limitations were persistent, stable, and unlikely to remit over 15 months of follow-up in this sample of patients with established HIV infection.

Alcohol and drug use are common among HIV-infected patients and are important determinants of secondary transmission risk and medication adherence. As part of the Coping with HIV/AIDS in the Southeast (CHASE) Study, 611 HIV-infected patients were consecutively recruited from eight clinical care sites in five southeastern U.S. states in 2001-2002. We examined the distribution and predictors of alcohol and drug use in this sample with an emphasis on psychosocial predictors of use. In the prior 9 months, 27% of participants drank alcohol and 7% drank to intoxication at least weekly. The most common drugs used at least weekly were marijuana (12%) and crack (5%); 11% used a non--marijuana drug. 7% reported polysubstance use (use of multiple substances at one time) at least weekly. Injection drug use was rare (2% injected at least once in the past 9 months). There were few differences in alcohol and drug use across sociodemographic characteristics. Stronger adaptive coping strategies were the most consistent predictor of less frequent alcohol and drug use, in particular coping through action and coping through relying on religion. Stronger maladaptive coping strategies predicted greater frequency of drinking to intoxication but not other measures of alcohol and drug use. Those with more lifetime traumatic experiences also reported higher substance use. Interventions that teach adaptive coping strategies may be effective in reducing alcohol and substance use among HIV-positive persons.

Advances in the treatment of HIV and associated opportunistic infections (OIs) have led to dramatic reductions in HIV-related morbidity and mortality in the United States, but not all patients have benefited equally. A longitudinal analysis of the Coping with HIV/AIDS in the Southeast (CHASE) cohort evaluated sociodemographic, psychosocial, and clinical factors associated with HIV-related events (incident category C OI or AIDS-related death) among southern HIV-infected patients engaged in clinical care. Participants were followed for a median of 30 months (interquartile range, 17-34 months) after study enrollment (enrollment period December 2001 to April 2002). Ten percent of study participants (50/489) experienced an HIV-related event (incident category C OI and/or AIDS-related deaths) during study follow-up. The rate of HIV-related events was 4.8 per 100 patient-years of observation, and the rate of AIDS-related death was 1.5 per 100 patient-years of observation. In unadjusted survival analyses, younger age, lacking private health insurance, psychosocial trauma, depressive symptoms, lower baseline CD4 count, and less time on antiretroviral therapy during follow-up were associated with HIV-related events. In Cox proportional hazards analysis adjusting for covariates, patients who had suffered more psychosocial trauma (hazard ratio [HR] = 1.97, p = 0.04), who had lower baseline CD4 counts (HR = 0.48 per 100 cells/[mm.sup.3], p < 0.01), and who spent less time on antiretroviral therapy during follow-up (HR = 0.47, p = 0.02) were more likely to experience an HIV-related event.

A study was conducted to examine the relation between psychiatric comorbidity and virologic and immunologic response among patients initiating highly active antiretroviral therapy (HAART) at an academic medical center in the southeastern United States serving a heterogeneous patient population. The findings are found to be consistent with an inferior virologic response to first HAART among patients with concurrent mood, anxiety, and substance use disorders.

Logistic regression models are developed to predict any Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition mood/anxiety disorder, any substance abuse, and certain specific diagnoses. Because psychiatric disorders have important implications for clinical management of HIV/AIDS, the results suggest potential benefit of routine integration of mental health identification and treatment into HIV service sites.

A validation study of the substance abuse and mental illness Symptoms Screener that was conducted in an HIV-positive patient population is described. It is found that people screening positive results in HIV need a more rigorous confirmatory psychiatric evaluation.

Background: As antiretroviral therapy (ART) for HIV becomes increasingly available in low and middle income countries (LMICs), understanding reasons for lack of adherence is critical to stemming the tide of infections and improving health. Understanding the effect of psychosocial experiences and mental health symptomatology on ART adherence can help maximize the benefit of expanded ART programs by indicating types of services, which could be offered in combination with HIV care. Methodology: The Coping with HIV/AIDS in Tanzania (CHAT) study is a longitudinal cohort study in the Kilimanjaro Region that included randomly selected HIV-infected (HIV+) participants from two local hospital-based HIV clinics and four free-standing voluntary HIV counselling and testing sites. Baseline data were collected in 2008 and 2009; this paper used data from 36 month follow-up interviews (N = 468). Regression analyses were used to predict factors associated with incomplete self-reported adherence to ART. Results: Incomplete ART adherence was significantly more likely to be reported amongst participants who experienced a greater number of childhood traumatic events: sexual abuse prior to puberty and the death in childhood of an immediate family member not from suicide or homicide were significantly more likely in the non-adherent group and other negative childhood events trended toward being more likely. Those with incomplete adherence had higher depressive symptom severity and post-traumatic stress disorder (PTSD). In multivariable analyses, childhood trauma, depression, and financial sacrifice remained associated with incomplete adherence. Discussion: This is the first study to examine the effect of childhood trauma, depression and PTSD on HIV medication adherence in a low income country facing a significant burden of HIV. Allocating spending on HIV/AIDS toward integrating mental health services with HIV care is essential to the creation of systems that enhance medication adherence and maximize the potential of expanded antiretroviral access to improve health and reduce new infections. [ABSTRACT FROM AUTHOR]

Background: The care and protection of the estimated 143,000,000 orphaned and abandoned children (OAC) worldwide is of great importance to global policy makers and child service providers in low and middle income countries (LMICs), yet little is known about rates of child labour among OAC, what child and caregiver characteristics predict child engagement in work and labour, or when such work infers with schooling. This study examines rates and correlates of child labour among OAC and associations of child labour with schooling in a cohort of OAC in 5 LMICs. Methods: The Positive Outcomes for Orphans (POFO) study employed a two-stage random sampling survey methodology to identify 1480 single and double orphans and children abandoned by both parents ages 6-12 living in family settings in five LMICs: Cambodia, Ethiopia, India, Kenya, and Tanzania. Regression models examined child and caregiver associations with: any work versus no work; and with working <21, 21-27, and 28+ hours during the past week, and child labour (UNICEF definition). Results: The majority of OAC (60.7%) engaged in work during the past week, and of those who worked, 17.8% (10.5% of the total sample) worked 28 or more hours. More than one-fifth (21.9%; 13% of the total sample) met UNICEF's child labour definition. Female OAC and those in good health had increased odds of working. OAC living in rural areas, lower household wealth and caregivers not earning an income were associated with increased child labour. Child labour, but not working fewer than 28 hours per week, was associated with decreased school attendance. Conclusions: One in seven OAC in this study were reported to be engaged in child labour. Policy makers and social service providers need to pay close attention to the demands being placed on female OAC, particularly in rural areas and poor households with limited income sources. Programs to promote OAC school attendance may need to focus on the needs of families as well as the OAC. [ABSTRACT FROM AUTHOR]

Objetivo: En una época de terapias antirretrovíricas muy activas, los autores necesitaban confirmar los resultados previos de que el estrés y la depresión tienen un efecto en la evolución de la enfermedad por el virus de la inmunodeficiencia adquirida (VIH). El objetivo del presente estudio fue analizar los efectos de los traumas a lo largo de la vida, los acontecimientos estresantes recientes y la depresión en la mortalidad por todas las causas y en la mortalidad relacionada con el SIDA en varones y mujeres infectados por el VIH. Los autores plantearon la hipótesis de que estas variables psicosociales predecirían una mortalidad por todas las causas y específica por el VIH significativamente más rápida. Método: Los autores estudiaron una muestra consecutiva de varones y mujeres infectados por el VIH que recibían atención en una de ocho clínicas para enfermedades infecciosas de cinco estados del sudeste de EE.UU. La muestra incluyó a 490 pacientes a los que se hizo el seguimiento durante 27 meses mediante entrevista y el seguimiento de sus historias clínicas hasta 41 meses. Resultados: Se produjeron 29 muertes; 16 relacionadas con el SIDA. Mayor cantidad de traumas a lo largo de toda la vida y un marcador antigénico en el linfocito T colaborador-inductor (CD4) < 200 predijeron significativamente la mortalidad más rápida por todas las causas y relacionada con el SIDA. En todos los participantes con una mediana igual o superior de traumas, la tasa de muerte por todas las causas fue de 3,54 por 100 personas/año, en comparación con 1,72 en los que estaban por debajo de la mediana. En los participantes con una mediana igual o superior de traumas, la tasa de muerte relacionada con el SIDA fue de 2,13 por 100 personas/año, en comparación con 0,77 en los que estaban por debajo de la mediana. Los síntomas depresivos y la viremia inicial más elevada se relacionaron significativamente con un mayor riesgo de mortalidad relacionada con el SIDA. Conclusiones: Es preciso hacer más estudios para determinar si las intervenciones dirigidas a los traumas y la depresión pueden modificar estos efectos nocivos en la enfermedad por VIH. [ABSTRACT FROM AUTHOR]

Objective: Traumatic life histories are highly prevalent in people living with HIV/AIDS and predict sexual risk behaviors, medication adherence, and all-cause mortality. Yet the causal pathways explaining these relationships remain poorly understood. We sought to quantify the association of trauma with negative behavioral and health outcomes and to assess whether those associations were explained by mediation through psychosocial characteristics., Methods: In 611 outpatient people living with HIV/AIDS, we tested whether trauma's influence on later health and behaviors was mediated by coping styles, self-efficacy, social support, trust in the medical system, recent stressful life events, mental health, and substance abuse., Results: In models adjusting only for sociodemographic and transmission category confounders (estimating total effects), pasttrauma exposure was associated with 7 behavioral and health outcomes including increased odds or hazard of recent unprotected sex [odds ratio (OR) = 1.17 per each additional type of trauma, 95% confidence interval = 1.07 to 1.29], medication nonadherence (OR = 1.13, 1.02 to 1.25), hospitalizations (hazard ratio = 1.12, 1.04 to 1.22), and HIV disease progression (hazard ratio = 1.10, 0.98 to 1.23). When all hypothesized mediators were included, the associations of trauma with health care utilization outcomes were reduced by about 50%, suggesting partial mediation (eg, OR for hospitalization changed from 1.12 to 1.07), whereas point estimates for behavioral and incident health outcomes remained largely unchanged, suggesting no mediation (eg, OR for unprotected sex changed from 1.17 to 1.18). Trauma remained associated with most outcomes even after adjusting for all hypothesized psychosocial mediators., Conclusions: These data suggest that past trauma influences adult health and behaviors through pathways other than the psychosocial mediators considered in this model.

Background: Expanded access to antiretroviral therapy (ART) has produced dramatic reductions in HIV-associated morbidity and mortality. Disparities in access to and benefit from ART have been observed by race, gender, and mental health status, however., Methods: From 2001 to 2002, 611 HIV-positive patients were consecutively recruited from 5 southeastern US states and followed for 3 years. We evaluated demographic and psychosocial predictors of probability of receiving ART among all those eligible for ART (on ART, CD4 <350 cells/mm3 or viral load [VL] >55,000 copies/mL in the year preceding enrollment), time to first ART discontinuation among those on ART, and time to VL >400 copies/mL among those on ART with VL <400 copies/mL at enrollment., Results: Of 611 participants, 474 consented to medical record abstraction and had known ART status at enrollment; 81% (385 of 474) of all participants and 89% (385 of 435) of ART-eligible participants were receiving ART at enrollment. In multivariable analyses, ART receipt was associated with greater age (adjusted odds ratio = 1.92 per 10 years, 95% confidence interval: 1.23 to 3.01), fewer recent stressful life events (odds ratio = 0.68, 95% confidence interval: 0.51 to 0.92), less alcohol use (odds ratio = 0.64, 95% confidence interval: 0.46 to 0.90), and greater perceived self-efficacy (OR = 2.82, 95% confidence interval: 1.41 to 5.62). No psychosocial characteristics were associated with ART discontinuation or virologic failure. No racial/ethnic or gender disparities were observed in ART receipt; however, minority racial/ethnic groups were faster to discontinue ART (adjusted hazard ratio = 2.44, 95% confidence interval: 1.33 to 4.49) and experience virologic failure (adjusted hazard ratio = 2.01, 95% confidence interval: 1.09 to 3.71)., Conclusions: Patients with unfavorable psychosocial profiles were less likely to be on ART, perhaps attributable to providers' or patients' expectations of readiness. Psychosocial characteristics were not associated with ART discontinuation or virologic failure, however, possibly reflecting the selection process involved in who initiates ART. Racial disparities in ART discontinuation and virologic failure merit further attention.