Predictors of Outcomes of HIV-Infected Males
Constance R. Uphold PhD MS BS
North Florida/South Georgia Veterans Health System
Gainesville, FL
Funding Period: October 2000 - September 2005

BACKGROUND/RATIONALE:
Certain segments of the HIV-infected population, such as older, rural and nonwhite patients, progress to AIDS more rapidly than other subgroups. The goal of this project was to understand the reasons for these variations among vulnerable subgroups. The following three hypotheses were tested:
1. Age, rurality, and race/ethnicity are independently predictive of clinical outcomes (health-related quality of life [HRQOL], immunity, and viral load) over time.
2. Biopsychosocial variables (testosterone, body cell mass index, stress, health promoting behaviors, risk behaviors, social support) are independently predictive of clinical outcomes (HRQOL, immunity, viral load) over time.
3. Age, rurality, and race/ethnicity are independently predictive of the biopsychosocial variables (testosterone, body cell mass index, stress, health promoting behaviors, risk behaviors, social support) over time.

OBJECTIVE(S):
Certain segments of the HIV-infected population, such as older, rural and nonwhite patients, progress to AIDS more rapidly than other subgroups. The goal of this project was to understand the reasons for these variations among vulnerable subgroups. The following three hypotheses were tested:
1. Age, rurality, and race/ethnicity are independently predictive of clinical outcomes (health-related quality of life [HRQOL], immunity, and viral load) over time.
2. Biopsychosocial variables (testosterone, body cell mass index, stress, health promoting behaviors, risk behaviors, social support) are independently predictive of clinical outcomes (HRQOL, immunity, viral load) over time.
3. Age, rurality, and race/ethnicity are independently predictive of the biopsychosocial variables (testosterone, body cell mass index, stress, health promoting behaviors, risk behaviors, social support) over time.

METHODS:
This is a prospective cohort study of men attending three infectious disease clinics: VA medical center (n = 131), health department (n = 55), university hospital (n = 40). Data were collected from 226 men at baseline, 197 men at a 12-month follow-up, and 184 men at a 24-month follow up. Trained research assistants obtained information on stress (modified Psychiatric Epidemiological Research Interview), health promoting behaviors (Health Promoting Lifestyle Profile II), risk behaviors (selected items from national screening tools and previous HIV studies), social support (Social Support Appraisal), medication adherence (Patient Medication Adherence Questionnaire 7), comorbidity (Charlson Comorbidity Index Questionnaire) and health-related quality of life (HIV Cost & Services Utilization Study) with questionnaires. Subjects’ blood was analyzed for total and free testosterone and IL-6 at each time point. CD4 cells, memory CD4 cells, naïve CD4 cells and viral loads (HIV RNA levels) were measured every 3 months. Bioelectrical impedance analyses measured body cell mass index. Interaction terms were explored to determine varying effects of the independent varaibles on outcomes across time. Interactions were nonsignificant and thus, only the main effects were included in the models. Multivariate analysis was used to determine whether the independent varaibles were associated with the set of HRQOL outcomes after adjusting for covariates (i.e., education level, comorbidity, medication adherence, initial CD4 cell count, duration of HIV diagnosis). Then, analyses for each dependent variable were performed using General Linear Model (GLM) with repeated measures at all the time points.

FINDINGS/RESULTS:
This is a prospective cohort study of men attending three infectious disease clinics: VA medical center (n = 131), health department (n = 55), university hospital (n = 40). Data were collected from 226 men at baseline, 197 men at a 12-month follow-up, and 184 men at a 24-month follow up. Trained research assistants obtained information on stress (modified Psychiatric Epidemiological Research Interview), health promoting behaviors (Health Promoting Lifestyle Profile II), risk behaviors (selected items from national screening tools and previous HIV studies), social support (Social Support Appraisal), medication adherence (Patient Medication Adherence Questionnaire 7), comorbidity (Charlson Comorbidity Index Questionnaire) and health-related quality of life (HIV Cost & Services Utilization Study) with questionnaires. Subjects’ blood was analyzed for total and free testosterone and IL-6 at each time point. CD4 cells, memory CD4 cells, naïve CD4 cells and viral loads (HIV RNA levels) were measured every 3 months. Bioelectrical impedance analyses measured body cell mass index. Interaction terms were explored to determine varying effects of the independent varaibles on outcomes across time. Interactions were nonsignificant and thus, only the main effects were included in the models. Multivariate analysis was used to determine whether the independent varaibles were associated with the set of HRQOL outcomes after adjusting for covariates (i.e., education level, comorbidity, medication adherence, initial CD4 cell count, duration of HIV diagnosis). Then, analyses for each dependent variable were performed using General Linear Model (GLM) with repeated measures at all the time points.

IMPACT:
Surprisingly, age was the only socio-demographic factor associated with many positive factors (more health behaviors, less stress, better mental health). Professionals should concentrate on the positive aspects of aging with HIV and not view older age as a liability. Factors, which nurses can modify, were strongly associated with HRQOL outcomes. Programs are recommended to reduce stress and enhance social support and health behaviors, particularly for younger men who appear to be at greatest risk.

PUBLICATIONS:

Journal Articles

1. Frame MW, Uphold CR, Shehan CL, Ried KJ. Longitudinal effects of spirituality on stress, depression and risk behaviors among men with HIV/AIDs. Journal of Spirituality in Mental Health. 2008; 10(2): 145-168.
2. Uphold CR, Holmes W, Reid K, Findley K, Parada JP. Healthy lifestyles and health-related quality of life among men living with HIV infection. Journal of The Association of Nurses in AIDS Care. 2007; 18(6): 54-66.
3. Mkanta WN, Uphold CR. Theoretical and methodological issues in conducting research related to health care utilization among individuals with HIV infection. AIDS Patient Care and Stds. 2006; 20(4): 293-303.
4. Cole SB, Langkamp-Henken B, Bender BS, Findley K, Herrlinger-Garcia KA, Uphold CR. Oxidative stress and antioxidant capacity in smoking and nonsmoking men with HIV/acquired immunodeficiency syndrome. Nutrition in Clinical Practice. 2005; 20(6): 662-7.
5. Frame MW, Uphold CR, Shehan CL, Reid KJ. The effects of spirituality on health-related quality of life in men with HIV/AIDS. Counseling and Values. 2005; 50(1): 5-19.
6. Tromble-Hoke SM, Langkamp-Henken B, Reid K, Hoffinger R, Uphold CR. Severe stress events and use of stress-management behaviors are associated with nutrition-related parameters in men with HIV/AIDS. Journal of The American Dietetic Association. 2005; 105(10): 1541-8; quiz 1550.
7. Uphold CR, Rane D, Reid K, Tomar SL. Mental health differences between rural and urban men living with HIV infection in various age groups. Journal of Community Health. 2005; 30(5): 355-75.
8. Jia H, Uphold CR, Wu S, Chen GJ, Duncan PW. Predictors of changes in health-related quality of life among men with HIV infection in the HAART era. AIDS Patient Care and Stds. 2005; 19(6): 395-405.
9. Shehan CL, Uphold CR, Bradshaw P, Bender JM, Arce N, Bender BS. To tell or not to tell: men's disclosure of their HIV-positive status to their mothers. Family Relations. 2005; 54(2): 184-196.
10. Burg MA, Uphold CR, Findley K, Reid K. Complementary and alternative medicine use among HIV-infected patients attending three outpatient clinics in the Southeastern United States. International Journal of STD & AIDS. 2005; 16(2): 112-6.
11. Jia H, Uphold CR, Wu S, Reid K, Findley K, Duncan PW. Health-related quality of life among men with HIV infection: effects of social support, coping, and depression. AIDS Patient Care and Stds. 2004; 18(10): 594-603.
12. Uphold CR, Deloria-Knoll M, Palella FJ, Parada JP, Chmiel JS, Phan L, Bennett CL. US hospital care for patients with HIV infection and pneumonia: the role of public, private, and Veterans Affairs hospitals in the early highly active antiretroviral therapy era. Chest. 2004; 125(2): 548-56.

DRA: Chronic Diseases, Health Services and Systems, Special (Underserved, High Risk) Populations
DRE: Technology Development and Assessment, Diagnosis and Prognosis, Treatment
Keywords: Nursing, Patient outcomes, Rural
MeSH Terms: Outcome Assessment (Health Care), HIV