Older MSM Research Articles

Anal cytological abnormalities and epidemiological correlates among men who have sex with men at risk for HIV-1 infection

BackgroundThe incidence of anal cancer, a Human Papillomavirus (HPV)-related neoplasia, has been increasing in recent decades, mainly in men who have sex with men (MSM). Cytological changes of the anal epithelium induced by HPV can be detected through an anal pap smear. This study aimed to evaluate the prevalence and epidemiological correlates of anal cytological abnormalities among relatively young MSM at risk for HIV-1 infection, to help clarify whether or not this population deserves further investigation to assess the presence of anal cancer precursor lesions.MethodsMSM were recruited among attendees of a large STI clinic for a HIV-1 screening program. Anal samples, collected with a Dracon swab in PreservCyt, were used both for liquid-based cytology and HPV testing by the Linear Array HPV Genotyping Test. Data regarding socio-demographic characteristics and sexual behavior were collected in face-to-face interviews.ResultsA total of 346 MSM were recruited (median age 32 years). Overall, 72.5% of the individuals had an anal HPV infection, with 56.1% of them being infected by oncogenic HPV genotypes. Anal cytological abnormalities were found in 29.8% of the cases (16.7% ASC-US and 13.1% L-SIL). Presence of ASC-US+ was strongly associated with infection by any HPV type (OR=4.21, 95% CI: 1.97-9.23), and particularly by HPV 16 and/or 18 (OR=5.62, 95% CI: 2.33-13.81). A higher proportion of ASC-US+ was found in older MSM, in those with a higher number of lifetime partners and in those with a history of ano-genital warts. However, none of these variables or the others analyzed showed any significant association with abnormal cytological findings.ConclusionsThe presence of anal cytological abnormalities in about one third of the recruited MSM and their strong association with HPV infection, in particular that caused by HPV 16 and/or 18, might provide a further complement to the data that now support the introduction of HPV vaccination among MSM to protect them from the development of HPV-associated diseases. Additional studies are needed to determine whether and how screening for anal cancer precursor lesions should be performed in younger MSM.

Prevalence of Urethral Trichomonas vaginalis in Black and White Men Who Have Sex With Men

To the Editor: Trichomonas vaginalis (TV) is a common nonulcerative sexually transmitted infection (STI) that has been associated with increased acquisition of human immunodeficiency virus (HIV) infection in women.1,2 Nucleic acid amplification testing for TV is more sensitive than traditionally used methods of detection, such as wet preparation or culture, and can facilitate the diagnosis of TV infection in both men and women.3 The prevalence of TV is estimated at 3.1% for US women, with black women being disproportionately affected by TV with a prevalence of 13.3%.4 Prevalence estimates among men are variable and reported between 3% and 17% for men attending STI clinics and as high as 72% for male partners of females diagnosed with vaginal TV.5–8 However, data on racial disparities among men are lacking. The incidence of HIV among black men who have sex with men (MSM) is at least 2 to 3 times that of white MSM, and differences in the prevalence of STIs are thought to contribute to disparities in HIV incidence among black and white MSM.9,10 However, the limited data available suggest that TV is a rare cause of urethral and rectal infection in MSM.8,11,12 Given its potential implications for disparities in HIV transmission among MSM, we assessed TV prevalence among community- recruited black and white MSM in the southeast. The Emory InvolveMENt study is currently enrolling a longitudinal cohort with plans to eventually enroll approximately 1000 MSM. The study is designed to examine individual-, dyadic-, and community-level factors that may explain disparities in HIV and STI incidence between black and white MSM. MSM aged 18 to 39 years, regardless of HIV serostatus, who reported having sex with another male in the previous 3 months and not being in a mutually monogamous relationship were recruited from community-based venues and via the internet in Atlanta, GA, surveyed, and tested for urethral TV as part of a standard battery of STI tests. MSM were not queried for symptoms of STI before testing. The presence of TV in urine specimens was assessed using a real-time polymerase chain reaction test that was developed and validated in our Center for AIDS Research Clinical Virology Core laboratory with sensitivity and specificity of 100% and 99.6%, respectively, and a limit of detection of <0.2 organisms per reaction or 40 copies/mL.13 Between July 2010 and February 2012, a total of 319 black MSM (42.0% HIV positive) and 281 white MSM (14.6% HIV positive) were tested for urethral TV at their first InvolveMENt study visit. No man refused TV testing, and 100% of urine specimens were adequate for analysis. None of the urine specimens from black (exact 95% confidence interval, 0%–0.94%) or white (exact 95% confidence interval, 0%–1.06%) MSM tested positive for urethral TV. Given these results, we have discontinued all TV testing in our study. Our data confirm previous studies that suggested TV is not a common cause of urethral infection in MSM. Furthermore, our data add to existing data by showing that clinically important racial disparities in TV prevalence reported among heterosexuals are likely not present among MSM.8,11,12 Our data are limited in that our study was conducted in 1 geographic area (Atlanta, GA) among community-recruited MSM aged 18 to 39 years and may not be generalizable. For example, older MSM or MSM attending STI clinics may have a higher prevalence of TV infection. In addition, we did not assess men for symptoms of urethritis before testing for TV, and TV prevalence could be higher among MSM with symptomatic urethritis. Nonetheless, our data show that differences in TV prevalence by race are not likely to be an important driver of disparities in HIV transmission among black and white MSM. In addition, the inclusion of routine TV screening in asymptomatic, sexually active MSM for clinical or research purpose is likely to be of very low utility.

A comparison of HIV risk practices among unprotected sex-seeking older and younger men who have sex with other men

Purpose: In recent years, much attention has been devoted to understanding the HIV risk behaviors of younger men who have sex with men (MSM). Recent data suggest that HIV is becoming an increasing problem for older adults, but little attention has been devoted to understanding their HIV risk behaviors or the factors that underlie their risk taking. This study provides a comparison of these issues among younger and older MSM. Methods: The data come from a subset of younger (ages 18–39, n = 113) and older (ages 50+, n = 109) men participating in a national study of 332 men who use the Internet to find other men for unprotected sex. Men were sampled randomly from 16 websites. Data were collected via telephone interviews conducted in 2008 and 2009. Results: Younger and older men reported comparable involvement in HIV risk, including involvement in unprotected sex, proportion of sex acts involving internal ejaculation, number of times having anonymous sex, and number of times having multiple-partner sex. Generally speaking, the factors underlying the risk practices of younger and older men were quite different (e.g. self-esteem and condom use self-efficacy for younger men, versus HIV serostatus and depression for older men). Conclusions: Older MSM using the Internet to find partners for unprotected sex engage in high rates of behaviors that place them at risk for contracting or transmitting HIV. They were just as likely as their younger counterparts to practice these behaviors. The factors “fueling” involvement in risk generally differ for older and younger men, thereby warranting the development of age-specific HIV interventions that can take into account the unique life circumstances and needs of older MSM.

Trends in early and late diagnosis of HIV-1 infections in Tokyoites from 2002 to 2010

The objective of this study was to delineate the trends in early and late diagnosis of HIV-1 infection in newly diagnosed Tokyoites. The BED assay was used to identify cases diagnosed at an early stage of infection. BED-positive non-AIDS cases with a CD4 cell count ≥ 200/μl were defined as cases with recent infection. The rates of AIDS and recent infection in 809 newly diagnosed Tokyoites during 2002-2010 were analyzed. The AIDS rate was 22.5%. AIDS patients were older (40.4 years) than non-AIDS patients (35.0 years), and a smaller proportion were men who have sex with men (MSM) in AIDS patients (81.7%) than in non-AIDS patients (89.9%). The AIDS rate was persistently lower (≤ 14.3%) in ≤ 29-year-old than in ≥ 30-year-old MSM. The rate of recent infection was 24.4%. Individuals with recent infection (33.0 years old) were younger than the others (37.2 years). The rate of recent infection was lower (≤ 18.5%) in MSM aged ≥ 40 years than in those aged ≤ 39 years during the study period, except for 2007 and 2008. Younger MSM Tokyoites appear to be aware of the risk of their sexual behavior, sufficient to take voluntary HIV testing repeatedly, resulting in early diagnosis. Older MSM did not take HIV testing frequently enough and may be a good target for campaigns promoting testing.

Factors associated with unprotected anal intercourse and age among men who have sex with men who are gay bar customers in Osaka, Japan

HIV infections among men who have sex with men (MSM) are increasing in Japan. An anonymous self-administered questionnaire among clients of a gay bar in Osaka was used to analyse the relationship between age and unprotected anal sex (UAI). The highest rate of UAI was reported among those aged ≥45 (73.3%), followed by the ≤24 (60.7%), 25-34 (56.3%) and 35-44 (54.0%) age groups (P=0.01). In multivariate analysis, UAI was related to sex with six or more sexual partners among those aged ≤24 (adjusted odds ratio (AOR), 4.88; confidence interval (CI), 1.21-19.74), bisexual identity (AOR, 2.47; CI, 1.06-5.76) and drug use (AOR, 0.49; CI, 0.26-0.93 for no drug use) in the 25-34 age group, and no lifetime HIV testing in the 35-44 age group (AOR, 2.57; CI, 1.40-4.74). Condom purchasing and condom carrying were protective of UAI in 25-34, 35-44 and ≥45 age groups. Programs promoting condom use are needed for younger and older MSM.

Differences in risk behaviors and partnership patterns between younger and older men who have sex with men in New York City.

Men who have sex with men (MSM) account for a higher proportion of HIV diagnoses than any other risk group in the United States. Given that in NYC MSM younger than 30 years represent a growing proportion of new diagnoses among MSM, we examined differences between MSM by age. We analyzed NYC surveillance and partner services (PS) data for MSM newly diagnosed with HIV from January 2007 to December 2008. We compared demographics, HIV-related risk behaviors, and sexual partner characteristics between younger MSM (<30 years old) (YMSM) and MSM ≥30 years old. Three hundred and thirty-six MSM were interviewed for PS (180 YMSM and 156 older MSM). MSM were mostly black or Hispanic (91%). YMSM were more likely than older MSM to report gay sexual identity (70% vs. 58%, P < 0.01), and a recent sexually transmitted infection (29% vs. 15%, P < 0.01). More YMSM named ≥1 male partner for HIV notification (66% vs. 36%, P < 0.01). YMSM were more likely than older MSM to name partners who were 5 or more years older (42% vs. 25%, P < 0.01). More YMSM tested for HIV at least once in the past 2 years than older MSM (66% vs. 40%, P < 0.01). Our study has identified important differences in HIV risk behaviors and sexual partnerships between YMSM and older MSM newly diagnosed with HIV. YMSM were more willing to provide the names of male sex partners for the purposes of partner notification than were older MSM, suggesting that PS may be particularly effective at identifying new cases of HIV.

Late presentation of HIV infection among adults in New Zealand: 2005–2010

Early diagnosis of HIV infection is important for the individual and for disease control. A consensus was recently reached among European countries on definitions of timing of presentation for care: 'Late presentation' refers to entering care with a CD4 count <350 cells/μL or an AIDS-defining event, regardless of the CD4 count. Presentation with 'advanced HIV disease' is a subset having a CD4 count <200 cells/μL and also includes all who have an AIDS-defining event regardless of CD4 count. This study examines timing of presentation in New Zealand from 2005 to 2010. Since 2005, information on the initial CD4 cell count has been requested on all people newly diagnosed with HIV infection through antibody testing in New Zealand. Excluded in this analysis were those previously diagnosed overseas or for an immigration medical. A CD4 cell count was provided for 606 (80.3%) of the 755 newly diagnosed adults. Overall, 50.0% were 'late presenters' and 32.0% had 'advanced HIV disease'. Compared with men who have sex with men (MSM), people heterosexually infected were more likely to present late. 'Late presentation' and presentation with 'advanced HIV disease' were significantly more common among older MSM. Māori and Pacific MSM were more likely to present with 'advanced HIV disease'. Compared with European MSM, the age-adjusted relative risks for Māori and Pacific MSM were 2.1 [95% confidence interval (CI) 1.4-3.2] and 2.5 (95% CI 1.2-5.0), respectively. The high proportion of people presenting late reflects inadequate levels of HIV testing. The lower proportion of late presentations among MSM compared with those heterosexually infected may be explained by a higher proportion of recent locally acquired infections together with different testing patterns.

P1-S2.35 Increased HIV and primary and secondary syphilis diagnoses among young men who have sex with men, 2004–2008

BackgroundNational surveillance data document increases in HIV and syphilis diagnoses in young black men who have sex with men (MSM), but trends could be driven by increases in a few...

P1-S2.63 Association between Age and STI among men who have sex with men (MSM) in Jamaica

BackgroundIn 2007, 201 men who have sex with men were recruited at social venues and through peer referral in five urban areas of Jamaica for an exploratory study of the...

The Role of Alcohol and Substance Use in Risky Sexual Behavior Among Older Men Who Have Sex With Men: A Review and Critique of the Current Literature

HIV incidence is increasing among men who have sex with men (MSM) despite years of prevention education and intervention efforts. Whereas there has been considerable progress made in identifying risk factors among younger MSM, older MSM have been largely neglected. In particular, the role of alcohol and drug use in conjunction with sex has not been thoroughly studied in older MSM samples. This article reviews the small body of literature examining the association of substance abuse and risky sexual behavior in this population and provides a methodological critique of the reviewed studies. The data show that older MSM are engaging in risky sexual behavior, with the likelihood of engaging in risky sexual activities increasing with the use of alcohol and other drugs. Methodological limitations prevent strong conclusions regarding whether the sexual risk behaviors of older MSM differ from those of younger MSM, and the extent to which alcohol and drug use may differentially contribute to engagement in sexual risk-taking as a function of age. Future research is needed to clarify these associations.

Age Disparity Between Sex Partners of Men Who Have Sex With Men Is Only a Marker of HIV Risk

To the Editor: Hurt and colleagues observed that primary HIV infection (PHI) in men who have sex with men (MSM) was associated with selecting older sex partners.1 Specifically, MSM with PHI (median age, 24.5 years) tended to choose partners 5 years older (median, 29.8 years) compared with uninfected MSM who were much closer in age (22.5 years; partners, 23.9 years). This result is not surprising, because older MSM are more likely to be infected. In Colorado Springs, for example, rigorously sought, community-wide sexually transmitted disease/HIV surveillance data show that whereas chlamydia is an infection of the late teens and early 20s, and gonorrhea of the early to mid-20s,2 the average age for HIV seroconversion is late 20s (median, 27 years; mean, 27.8 years),3 an average age approaching that of older partners of men with PHI in Hurt and colleagues' study. What is remarkable is Hurt and colleagues' and Coburn and Blower's4 interpretation of the observed association between partner age disparity and PHI. They mislabel sex with an older man as a risk factor for HIV and correspondingly call for prevention messages to be refocused on this behavior.1,4 Sex with an older MSM cannot be a risk factor for HIV infection, although it is a risk marker. The fact that the age of sex partners remained an independent correlate of recent HIV infection in Hurt and colleagues' multivariate model reflects mismeasurement of exposure to HIV. It appears objective data on partners' HIV statuses were unavailable for 90% (18 of 20) of men with PHI and 46% (25 of 54) of uninfected men. It is unclear whether all such partners were classified as “serostatus unknown” (and thus regarded as having exposed participants to HIV) or their serostatuses were estimated from participants' perceptions (the authors did not describe such procedures). In the former scenario, uninfected men's exposure to HIV may be overestimated. In the latter scenario, men with PHI may have incorrectly perceived infected partners as uninfected or not reported partners during the period when they acquired infection because the authors collected data on the three most recent partners only. Other characteristics of partners can also serve as markers of HIV risk in MSM such as race5-7 and injection drug use.7 The social contexts in which MSM form sexual partnerships may be even better indicators of HIV risk.8,9 Although local data on risk markers might inform ancillary prevention messages, the educational focus in MSM should remain on avoiding the most direct risk factors-anal (especially receptive) intercourse without a condom and sex between serodiscordant men-as their own data clearly show.1 John J. Potterat, BA* Devon D. Brewer, PhD† *Health Department, Colorado Springs, CO †Interdisciplinary Scientific Research, Seattle, WA

The changing age distribution of men who have sex with men diagnosed with HIV in Victoria

To describe recent trends among men who have sex with men (MSM) in age at diagnosis of HIV in Victoria. Analysis of Victorian HIV surveillance data from (i) passive surveillance (2000-2009) and (ii) the Victorian Primary Care Network for Sentinel Surveillance (VPCNSS) (2006-2009). Age-trend comparisons were made using syphilis and gonorrhoea enhanced surveillance. HIV diagnoses, HIV testing and behavioural indicators by year and age group among MSM. Following a period of sustained increase between 2000 and 2007, the median age at HIV diagnosis among MSM declined significantly, from 38.8 years in 2007 to 35.3 years in 2008 (P=0.023), remaining at 35.9 years in 2009. Between 2007 and 2008, the median age of syphilis and gonorrhoea notifications also declined, from 40.6 to 36.0 years and from 32.3 to 29.3 years, respectively. The median age of HIV testing among MSM in the VPCNSS population remained constant between 2006 and 2009, at 33.0 years. Compared with older MSM, those aged less than 35 years were more likely to have never previously been tested for HIV (relative risk [RR], 1.36 [95% CI, 1.30-1.41]); to not know the HIV status of their regular partner (RR, 1.11 [95% CI, 1.01-1.21]); and to report inconsistent condom use with casual partners (RR, 1.07 [95% CI, 1.01-1.14]) and regular partners (RR, 1.07 [95% CI, 1.00-1.14]). Younger MSM in Victoria may be at increasing risk of HIV infection. Enhanced methods of monitoring HIV and sexually transmitted infection transmission in younger MSM are needed, as well as prevention messages to target this group, who may not fully understand their HIV risk.

HIV-related behavioral studies of men who have sex with men in China: a systematic review and recommendations for future research.

HIV prevalence among men who have sex with men (MSM) has increased significantly in China since early 2000, with MSM accounting for 32.5% of the newly infected HIV cases in China in 2009. This study reviews a total of 33 studies published in English literature on MSM in China from 2000 to 2009. Existing studies indicated that frequently MSM in China were married (especially older MSM); a majority were migrants and self-identified as gay. A large and increasing proportion of MSM sought sexual partners online. Sexual risk behaviors among MSM were prevalent, including high rates of unprotected sex, concurrent sexual relationships with both men and women, and commercial sex. Illicit drug use, however, was relatively low among general Chinese MSM, but higher among those engaged in commercial sex with men. The existing literature suggests a lack of socio-behavioral studies, lack of intervention studies specifically targeting MSM, and lack of studies in smaller cities, towns, and rural areas. Future studies need to employ more rigorous research methodology, including longitudinal study design, multiple sampling methods, and common measurements of HIV-related risk behaviors.

A Major HIV Risk Factor for Young Men Who Have Sex With Men Is Sex With Older Partners

A Major HIV Risk Factor for Young Men Who Have Sex With Men Is Sex With Older Partners

The Prevalence of Rectal, Urethral, and PharyngealNeisseria gonorrheaeandChlamydia trachomatisamong Asymptomatic Men Who Have Sex with Men in a Prospective Cohort in Washington, D.C.

The Prevalence of Rectal, Urethral, and Pharyngeal<i>Neisseria gonorrheae</i>and<i>Chlamydia trachomatis</i>among Asymptomatic Men Who Have Sex with Men in a Prospective Cohort in Washington, D.C.

Age and Racial/Ethnic Differences in the Prevalence of Reported Symptoms in Human Immunodeficiency Virus-Infected Persons on Antiretroviral Therapy

Few studies have evaluated age and racial/ethnic differences in the prevalence of symptoms in human immunodeficiency virus (HIV)-infected persons. Thus, the objective of this study was to compare the prevalence of gastrointestinal, metabolic, general malaise, neurologic, or other self-reported symptoms by age and race/ethnicity among 1574 HIV-infected women enrolled in the Women's Interagency HIV Study and 955 HIV-infected men who have sex with men (MSM) enrolled in the Multicenter AIDS Cohort Study. All patients had known dates of initiation of highly active antiretroviral therapy. It was observed that women aged 50 years or more were less likely to experience gastrointestinal symptoms (24% vs. 27%; multivariable P = 0.024), but more likely to experience general malaise (47% vs. 37%; multivariable P = 0.004), neurologic (44% vs. 38%; multivariable P = 0.048), or other symptoms (40% vs. 28%; multivariable P < 0.001) compared with women less than 40 years of age. Only neurologic symptoms had a higher prevalence among older MSM (52% vs. 37%; multivariable P = 0.002), largely driven by paresthesias (48% vs. 31%; multivariable P = 0.004), the most common individual symptom reported by men. Caucasian women generally had the highest prevalence of symptoms, and African American women had the lowest prevalence. Few racial/ethnic differences were noted for MSM. Depression and a prior diagnosis of acquired immunodeficiency syndrome were the strongest and most consistent predictors of clinical symptoms in both cohorts. In summary, the prevalence of reported symptoms varies with patient race/ethnicity, age, and modifiable factors, such as depression and HIV disease stage. Clinicians should consider these factors when counseling patients regarding potential adverse effects of antiretrovirals or symptoms associated with HIV disease.

Moderating Effects of Age on the Alcohol and Sexual Risk Taking Association: An Online Daily Diary Study of Men Who have Sex with Men

Men who have sex with men (MSM) account for the majority of HIV/AIDS diagnoses and data suggest infection rates are rising. Identification of factors that increase the risk of infection is key to the development of effective prevention programs. Previous research has been inconsistent regarding the link between alcohol consumption and sexual risk taking among MSM. Daily reports of alcohol consumption and sexual behavior were completed for up to 30 days by 143 HIV negative MSM recruited online. This resulted in 2,887 daily reports of number of sex partners and 549 episodes of sex. Independent variables included age, number of standard drinks consumed, and partner type. Outcome variables included sex with a partner, a composite sexual risk variable, and unprotected anal intercourse (UAI). Alcohol consumption significantly increased the odds of having sex and had a significant positive association with the sexual risk composite variable. Age was a significant moderator of the association between alcohol consumption and sexual risk taking, with the effects of alcohol increasing with age. For example, at the 75%tile of age (37 years old), the odds of UAI increase from approximately 0.2 to 0.35 as the number of alcoholic drinks increases from zero to seven. Partner type did not have significant effects. Daily reports of alcohol consumption had a significant within-person association with sexual risk behaviors, particularly among older MSM. Findings highlight the importance of measuring individual differences as moderators of the association between alcohol and risky sexual behavior.

HIV incidence and HIV testing behavior in men who have sex with men: using three incidence sources, The Netherlands, 1984–2005

In The Netherlands, the western part, including Rotterdam and Amsterdam harbors the majority of the known HIV-infected population, of whom men who have sex with men (MSM) comprise the largest transmission category. Given a general rise in sexually transmitted infections (STI) and risky sexual behavior, we examine the HIV incidence among MSM in the Netherlands with data from three different sources. To describe the HIV epidemic among MSM we use: a prospective cohort study in Rotterdam (ROHOCO: 1998-2003, n = 265) and another in Amsterdam (ACS: 1984-2005, n = 1498]) plus an anonymous HIV surveillance study (Amsterdam STI clinic: 1991-2004, n = 3733) in which HIV-positive MSM were tested with a less-sensitive HIV assay. We evaluated calendar trends in HIV incidence, also focusing on age effects. Since the start of the HIV epidemic in the early 1980s, incidence has declined strongly in the ACS. In recent years, an increase was noted among older MSM attending the Amsterdam STI clinic (P = 0.0334). In both cohort studies, HIV incidence was lower and recent time-trends were not statistically significant. Among recently infected men at the STI clinic, only 40% accepted named HIV testing at their STI consultation. Data suggest that among MSM in the Netherlands, the HIV incidence is between one and four infections per 100 person-years. The epidemic expands among older STI clinic attendees. Prevention should be developed specifically for older men, along with a more efficient HIV testing approach such as routine HIV testing of MSM when they are screened for STI.

Association of Sleep Difficulty with Kidney Disease Quality of Life Cognitive Function Score Reported by Patients Who Recently Started Dialysis

Sleep disorders are associated with impaired cognition in the general population, but little attention has been given to the potential association between sleep and cognitive function in the dialysis population. This study investigated reported sleep difficulty and cognitive function scores in a national cohort of patients who initiated maintenance hemodialysis and peritoneal dialysis. The cognitive function scale of the Kidney Disease Quality of Life instrument (KDQOL-CF), which measures aspects of cognitive ability that are important for daily functioning (perceived reaction time, ability to concentrate, and tendency to become confused), was used. The study population included 2286 patients who responded to a questionnaire at baseline in the US Renal Data System Dialysis Morbidity and Mortality Study Wave 2. Reported sleep difficulty was associated in a univariate manner with lower KDQOL-CF score. In a multivariable regression analysis that controlled for age, gender, race, education, diabetic ESRD, cardiovascular comorbidity, smoking, hemoglobin, serum albumin, prescribed sleep medications, dialysis modality, pre-ESRD care, bodily pain, and depressed mood, the association of sleep difficulty with KDQOL-CF score remained significant (P < 0.0001); the association also was significant in a multivariable analysis that was restricted to hemodialysis patients and included adjustment for Kt/V (P = 0.001). Depressed mood and sleep medication prescription predicted a lower KDQOL-CF score, and higher educational level and less bodily pain predicted a higher KDQOL-CF score. Increased understanding of links among sleep difficulty, management of sleep difficulty, and cognitive function could benefit multiple dimensions of dialysis patients' quality of life and daily functioning.

Letter to the Editor

Letter to the Editor