PTSD and its Associations with STIs – from Infection and Treatment to Morbidity and Mortality – among Veterans who Deployed to Iraq and Afghanistan Public
Vyas, Kartavya (Fall 2023)
Abstract
One-quarter of the 2.5 million Veterans who deployed to Iraq and Afghanistan post-9/11 are thought to have posttraumatic stress disorder (PTSD); many of whom may go on to develop other medical conditions of concern, including sexually transmitted infections (STIs). We aim to address a knowledge gap in the extant scientific literature for wartime Veterans and to help inform the care of all those with PTSD more broadly; of particular interest are Veterans with HIV (VWH).
In Aim 1 – Infection, Joinpoint regression models and marginal structural models were fitted to examine trends in PTSD and STI diagnoses, estimate the associations between PTSD and STI incidence, measure effect modification by number of deployments and combat exposure, and explore how these associations varied over time in a prospective cohort of all Veterans who deployed to Iraq and Afghanistan and received care in the VA between 7 October 2001 and 31 December 2022 (n=1,570,654). We found PTSD increased the rates of all STIs examined – chlamydia, genital HSV, gonorrhea, HBV, HCV, HIV, HPV, and syphilis.
In Aim 2 – Treatment, marginal structural models were fitted to estimate the associations between PTSD and HIV treatment non-adherence, modifications, and adverse outcomes; measure effect modification by number of deployments and combat exposure; and explore how these associations varied over time in a prospective cohort of all VWH on treatment who deployed to Iraq and Afghanistan and received care in the VA between 7 October 2001 and 31 December 2022 (n=3,206). We found PTSD increased the risk of HIV treatment non-adherence and the rate of HIV treatment modifications but was not associated with adverse outcomes.
In Aim 3 – Morbidity and Mortality, marginal structural models were fitted to estimate the associations between PTSD and 10 age-related comorbidities, multimorbidity, and all-cause mortality; measure effect modification by number of deployments and combat exposure; and explore how these associations varied over time in a prospective cohort of all VWH on treatment who deployed to Iraq and Afghanistan and received care in the VA between 7 October 2001 and 31 December 2022 (n=3,206). We found PTSD increased the risks of AIDS, arthritis, CKD, COPD, CVD, and multimorbidity but was not associated with asthma, cancer, CeVD, DM, liver disease, or mortality.
Individuals with PTSD have higher risks of STIs, treatment non-adherence, and some comorbid conditions. Results underscore the need for routine PTSD screening so that providers can better identify patients at increased risk of adverse outcomes and possibly mitigate these risks by referring them to risk reduction counseling or treatment advocacy programs.
Table of Contents
Chapter 1: Introduction
Specific aims
Aim 1 – Infection
Aim 2 – Treatment
Aim 3 – Morbidity and mortality
Systematic literature review
Background
Aim 1 – Infection
Aim 2 – Treatment
Aim 3 – Morbidity and mortality
References
Chapter 2: Overview of methods
Multiple imputation
Marginal structural models
Inverse probability treatment weights
Estimation of IPTWs
Inverse probability of censoring weights
Estimation of IPCWs
Estimation of final weights
Robust variance estimators
Assumptions
Interaction assessment
References
Chapter 3: PTSD and its associations with STIs among Veterans
Abstract
Key Points
Question
Findings
Meaning
Introduction
Methods
Study population
Data sources
Definitions
Descriptive analyses
Trend analyses
Inferential analyses
Results
Characteristics
Trends
Overall associations
Effect modification
Discussion
Conflicts of interest and source of funding
Author contributions
Acknowledgements
References
Chapter 4: PTSD and its associations with ART among Veterans with HIV
Abstract
Introduction
Methods
Study population
Data sources
Definitions
Descriptive analyses
Inferential analyses
Results
Characteristics
ART non-adherence
ART modifications
Treatment failure
Discussion
Author contributions
Declaration of interests
Data sharing
Acknowledgements
References
Chapter 5: PTSD and its associations with morbidity and mortality among Veterans with HIV
Abstract
Research in context
Evidence before this study
Added value of this study
Implications of all the available evidence
Introduction
Methods
Study population
Data sources
Definitions
Descriptive analyses
Inferential analyses
Results
Characteristics
Overall associations
Effect modification
Discussion
Author contributions
Declaration of interests
Data sharing
Acknowledgements
References
Chapter 6: Discussion
Major findings
Strengths and limitations
Potential impact
References
About this Dissertation
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