Ethics, Consent, and Permission
The Florida Cohort Study is an ongoing statewide prospective longitudinal study that seeks to identify factors that influence health outcomes in PLWH. This study is an analysis of data collected among PLWH living in Florida. The protocol was approved by the Institutional Review Boards (IRBs) at the University of Florida and the Florida Department of Health (DoH). All participants provided written informed consent as well as signed the Health Insurance Portability and Accountability Act (HIPPA) authorization form for use of their protected medical information.
Participants and Settings
Eligible participants were adults 18 years or older with a diagnosis of HIV. Participants were recruited from multiple cities in Florida (Gainesville, Ft. Lauderdale, Lake City, Miami, Orlando, Sanford, Tampa, and Wildwood) from 2014–2017. The study team’s recruitment efforts entailed posting brochures at community clinics and county health departments, having clinic/facility staff members reach out to potential participants, and consulting patient registries.
Measures
Participants completed study questionnaires during study enrollment. Data on demographics, HIV clinical outcomes, and the use of substances including alcohol, illicit drugs, and marijuana were obtained by self-report. Demographic variables included age, dichotomized as 18–49 and ≥ 50 years, and gender at birth (i.e., male or female), race/ethnicity (non-Hispanic Black, Hispanic, and non-Hispanic White), and employment status (employed or unemployed).
The questionnaire inquired about current and lifetime substance use of marijuana, alcohol, intravenous drug use (IDU), and crack/cocaine. Individuals indicating using marijuana during the past three months were categorized as current users while individuals abstaining from marijuana use were categorized as nonusers. Participants indicating any IDU or crack/cocaine use during the past year or during any period of time were categorized as lifetime users. Hazardous drinking was defined in concordance with the National Institute on Alcohol Abuse and Alcoholism (NIAAA) definition as consuming ≥ 14 drinks per week or ≥ 5 drinks per occasion at least monthly for men and ≥ 7 drinks per week or ≥ 4 drinks per occasion at least monthly for women.25
Participants who used marijuana were divided into two groups any recreational use and medicinal use only based on their self-reported reasons for use. In this study, recreational use was defined as using marijuana for the purpose of getting high or stoned, increasing libido/improving sexual performance, or fitting into social situations, while medicinal marijuana use was defined as using marijuana for the purpose of improving appetite/gaining weight, inducing sleep, relieving nausea/vomiting, relieving pain, or relieving anxiety/depression/stress. Participants reporting marijuana use for both recreational and medicinal purposes were classified as recreational users. This distinction was made due to prior research suggesting a variety of motives for marijuana use depending on recreational or medicinal use).26
This study employed the Brief Pain Inventory short form (BPI-SF)27 to assess the severity of the participants’ pain and to examine the impact of the experienced pain on each participant’s daily functioning. Using a scale of 1–10, participants were asked to rate their level of pain intensity, other than common pains, during the previous 24 hours, identifying the pain level at its worst, least, average, and current. In concordance with the BPI user guide, the average of the four pain level intensity scores reported by the participant provided a composite pain score.28 PLWH that did not report any pain during the previous 24 hours was categorized as no current pain. While, participants with an average score of ≥ 1 denotes current pain (Li, Harris, Hadi, & Chow, 2007).29 In order to account for the peak-end phenomenon, we utilized a cut-off score for worst pain of ≥ 6 in the secondary analysis of severe pain.24
The Generalized Anxiety Disorder Scale (GAD-7) was used to assess participants’ levels of anxiety. The GAD-7 is composed of seven items that screen for the presence of an anxiety disorder. Based on their responses, participants were dichotomized as having no symptoms of anxiety (score 0–9) or current anxiety symptoms (scores ≥ 10).30
Participants also completed the Patient Health Questionnaire (PHQ-8), consisting of 8 items to assess the frequency of depressive symptoms among the participants. Scores can range from 0 to 24, and participants were categorized as having no current depression symptoms (score 1–9), or current depressive symptoms (score ≥ 10). The PHQ-8 has demonstrated high reliability and is a well-validated measure for assessing depressive symptoms among PLWH.31
The Primary Care Post Traumatic Stress Disorder Screener (PC-PTSD), which contains 4 items, is a self-reported questionnaire designed to assess symptoms of PTSD. Individuals indicating one or more symptom(s) were coded as positive for PTSD symptoms.32
Statistical Analyses
Data were analyzed using SAS (Statistical Analysis Software) version 9.4. First, we assessed the bivariate relationships of mental health conditions, substance use, and sociodemographic factors associated with pain. We utilized simple logistic regression modeling to report the unadjusted odds ratios of the associations between these factors and pain scores. We then used a multivariate logistic regression to distinguish the relationship between mental health, substance use, sociodemographic factors, and any pain. In this multivariate logistic regression model, no pain was assigned as the referenced pain level. We then used a multivariate logistic regression to distinguish the relationship between mental health, substance use, and sociodemographic factors associated with worst pain. In this multivariate logistic regression model, the reference category was pain scored between 1–6. All data analyses were conducted using SAS version 9.4.