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Studies examine the HIV/AIDS epidemic in the South

HIV/AIDS infection in the United States is spreading the fastest in the South and its victims tend to be poor, minorities, and survivors of abuse. Also, Southern women and minorities are less likely than others to be on antiretroviral therapy (ART), according to a new study.

A second study shows that psychosocial trauma, less time on ART, and other factors are associated with HIV disease progression and death. Both Coping with HIV/AIDS in the Southeast (CHASE) studies were supported by the Agency for Healthcare Research and Quality (T32 HS00079).

The CHASE studies correlated patient sociodemographic and psychosocial characteristics with care processes and clinical outcomes for 611 patients enrolled in 2001 and 2002. The patients received HIV/AIDS care at eight infectious disease clinics in five Southeastern States and were followed for a median of 30 months. The studies are briefly described here.

Pence, B.W., Reif, S., Whetten, K., and others (2007, November). "Minorities, the poor, and survivors of abuse: HIV-infected patients in the US Deep South." Southern Medical Journal 100(11), pp. 1114-1122.

This study revealed the shift in the HIV/AIDS epidemic in the U.S. South toward a greater proportion of women and blacks, who become infected through heterosexual contact. It also found that more than half (54 percent) of patients with HIV infection from five Southeastern States suffer from probable psychiatric disorders, nearly a third (30 percent) have a history of childhood sexual abuse, and 21 percent suffer from severe physical abuse. Overall, nearly two-thirds of the group (64 percent) were black (compared with 50 percent nationally), 31 percent were female (compared with 26 percent nationally), and 43 percent acquired HIV through heterosexual sex (vs. 28 percent nationally).

Only 25 percent of the group had private health insurance. Women on average had been diagnosed with HIV more recently than men (mean 6.1 vs. 7.1 years ago), were less likely to have a suppressed viral load at baseline (36 vs. 51 percent), and tended to be less likely to be on ART if eligible (86 vs. 92 percent). Blacks had been diagnosed with HIV more recently than whites (mean of 6.4 vs. 7.6 years), were more likely to have a CD4 cell count indicating advanced disease (27 vs. 14 percent), were less likely to have a suppressed viral load (39 vs. 60 percent), and were less likely to receive ART if eligible (88 vs. 94 percent).

Only one-fourth of this group (26 percent) was not affected by childhood trauma, mental illness, or substance abuse. Over half had suffered three or more different types of trauma in their lifetime, 40 percent had a history of sexual or severe physical abuse before age 18, and 54 percent were currently diagnosed with posttraumatic stress disorder or a probable psychiatric disorder. Also, 14 percent became intoxicated at least weekly or had used illicit drugs (beyond marijuana) in the past 9 months. This group is at high risk for poor HIV clinical outcomes, conclude the researchers.

Mugavero, M.J., Pence, B.W., Whetten, K., and others (2007). "Predictors of AIDS-related morbidity and mortality in a Southern U.S. cohort." AIDS Patient Care and STDs 21(9), pp. 681-690.

Patients with HIV infection who had suffered more psychosocial trauma, had lower baseline CD4 counts (an indicator of more advanced disease progression), and who had spent less time on ART, were more likely to experience an HIV-related opportunistic infection or death 17 to 34 months later, found this study.

Use of ART has dramatically reduced so-called opportunistic infections among persons with HIV/AIDS. Opportunistic infections, such as certain types of pneumonia or primary central nervous system lymphoma, typically develop when CD4 cell count drops below 200, and indicate advanced disease progression. Ten percent of patients studied suffered an HIV-related opportunistic infection or death during followup. After adjusting for other factors, patients who had suffered more psychosocial trauma had nearly twice the likelihood and those without private health insurance had nearly three times the likelihood of experiencing an HIV-related infection or death. Patients who had lower baseline CD4 counts and who spent less time on ART were also more likely to develop an opportunistic infection or die.

These findings demonstrate a definite link between psychosocial trauma and development of opportunistic infections or death among patients with HIV/AIDS, even after adjusting for baseline CD4 counts and use of ART. These findings are striking, given the extremely high prevalence of sexual and physical abuse and other traumas among these HIV/AIDS patients in the Deep South, note the researchers. They suggest that early traumatic experiences are associated with later mental illness, substance abuse, and ART nonadherence, which place these patients at increased risk of poor health outcomes.

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