AIDS deaths shift from hospital to home. AIDS Mortality Project Group

OBJECTIVE

This study monitors trends in place of death among persons with acquired immunodeficiency syndrome (AIDS) as a measure of health care usage patterns and terminal health care among persons infected with human immunodeficiency virus (HIV).

METHODS

Sixteen health departments collected death certificates for 55,186 persons with AIDS whose deaths occurred through 1991. Place of death was categorized as hospital, residence, hospice or nursing home, and other.

RESULTS

The percentage of AIDS deaths at hospital facilities decreased from 92% in 1983 to 57% in 1991. In 1988, 23% of deaths occurred at home or in hospices and nursing homes. This trend was more evident among men, Whites, and men who had sex with men; less so among persons with other modes of exposure; and not at all among injecting drug users and children with perinatally acquired AIDS. Place of death varied by geographic location, with the greatest percentage of hospital deaths in the Northeast (91%) and the greatest percentage of at-home deaths in the West (27%).

CONCLUSIONS

The percentage of AIDS deaths at home or in hospices and nursing homes has increased since 1983. These trends may reflect changes in hospital use for end-stage HIV infection. Decreasing hospitalization and increasing outpatient services and home care will decrease costs and may allow HIV-infected persons improved social support.

Causes of death among persons reported with AIDS

OBJECTIVES

This study describes causes of death in persons with acquired immunodeficiency syndrome (AIDS) and assesses the completeness of reporting of human immunodeficiency virus (HIV) infection or AIDS on death certificates of persons with AIDS.

METHODS

AIDS case reports were linked with death certificates in 11 local/state health departments; underlying and associated causes of death were available for 32,513 persons with AIDS who died.

RESULTS

HIV/AIDS was designated as the underlying cause of death for 46% of persons with AIDS who died between 1983 and 1986 and 81% of persons with AIDS who died since 1987 (the year specific coding procedures were implemented for HIV/AIDS). Most other underlying causes of death were conditions within the AIDS case definition (notably Pneumocystis carinii pneumonia), pneumonia, infections outside the AIDS case definition, and drug abuse. Unintentional injuries, suicide, and homicide were less common. HIV/AIDS was listed as underlying or associated on 88% of death certificates from 1987 to 1989; reporting varied primarily by HIV exposure category and time between diagnosis and death.

CONCLUSIONS

Physicians and other health care professionals should realize their critical role in accurately documenting HIV-related mortality on death certificates. Such data can ultimately influence the allocation of health care resources for HIV-infected individuals.

Sociodemographics and HIV risk behaviors of bisexual men with AIDS: results from a multistate interview project

OBJECTIVE

To describe the sociodemographic characteristics and sexual and drug use behaviors of men with AIDS who engage in bisexual activity.

METHODS

We interviewed 2120 men aged > or = 18 years who were reported with AIDS in 11 states and cities. Men were considered bisexual if they reported having had sex with a man and a woman in the previous 5 years.

RESULTS

Of the 2020 men with AIDS who reported being sexually active in the previous 5 years, 1150 (57%) had had male partners only, 522 (26%) had had female partners only and 348 (17%) had had both. White men were least likely to report bisexual behavior (15%; 161 out of 1071). Men of Latin American descent were most likely to report bisexual behavior (24%; 37 out of 155), especially those born outside the United States who had lived there for < or = 10 years (38%; 11 out of 29). Bisexual Latin American men, regardless of birthplace, were more likely to be currently married than all other bisexual men (22 versus 7%; P < 0.05). HIV risk behaviors differed between men reporting bisexual and those reporting exclusively homosexual or heterosexual activity. Injecting drug use in the previous 5 years was more common among bisexual than homosexual men (12 versus 6%; P < 0.05). Bisexual men were more likely (P < 0.05) to have received money for sex (11%) than homosexual (4%) or heterosexual men (4%). This difference was even greater among injecting drug users receiving money for sex: bisexual (29%), homosexual (13%), heterosexual (3%).

CONCLUSIONS

Demographics and HIV risk behaviors of bisexual men with AIDS differ from those of homosexual and heterosexual men with AIDS. These findings indicate that special efforts are needed to prevent sexual transmission of HIV among bisexual men.

HIV infection as leading cause of death among young adults in US cities and states

OBJECTIVE

To describe the extent to which human immunodeficiency virus (HIV) infection has become the leading cause of death among young adults (25 to 44 years of age) in US states and cities of at least 100,000 population.

DESIGN

Analysis of underlying causes of death using national vital statistics for 1990 by state and city. Deaths caused by HIV were defined as those with underlying cause assigned a code number of 042, 043, or 044, as established by the National Center for Health Statistics.

RESULTS

Infection with HIV was the leading cause of death among young men in five states, causing 29% of their deaths in New York, 28% in New Jersey, 24% in California and Florida, and 16% in Massachusetts. Among young women, HIV was not the leading cause of death in any state. Among young men, HIV infection was the leading cause of death in 64 cities, with the proportion of deaths due to HIV ranging from 16% in Bridgeport, Conn, to 61% in San Francisco, Calif. Among young women, HIV infection was the leading cause of death in nine cities, with the proportion of deaths due to HIV ranging from 15% in Baltimore, Md, to 43% in Newark, NJ.

CONCLUSION

In many US communities, HIV infection is the leading cause of death among young men and women, causing a large proportion of deaths in this age group.

Effect of moderate or severe hepatic impairment on clarithromycin pharmacokinetics

The pharmacokinetic and safety profiles of clarithromycin (C) and its 14-hydroxy-clarithromycin (HC) metabolite were determined after a multiple-dose oral clarithromycin regimen (250 mg twice daily for five doses) in six healthy subjects and seven patients with moderate or severe hepatic impairment (Pugh grades B and C). Plasma and urine C and HC concentrations were determined using high-performance liquid chromatography. Hepatic impairment resulted in increased harmonic mean C terminal disposition half-life and mean +/- SD C renal clearance (CLR) compared with normal volunteers (5.0 vs. 3.3 hr and 170 +/- 69 vs. 111 +/- 17 mL/min, respectively). Hepatic impairment also resulted in decreased metabolite peak plasma concentration and area under the plasma concentration-versus-time curve and decreased metabolite/parent concentration ratios compared with normal volunteers. These data suggest that 14-hydroxylation of C was reduced by moderate to severe hepatic impairment. No adverse events were noted in either study group and there were no study-related clinically significant changes in laboratory parameters. The decrease in C metabolic clearance appears to be partially offset by an increase in C CLR, resulting in comparable steady-state concentrations of parent drug. In those indications in which the metabolite may be a necessary element of the antimicrobial activity of C, it would seem prudent to be cautious in using C in patients with moderate to severe hepatic impairment due to reduced production of HC. Otherwise, no dosage adjustment for C appears necessary for subjects with moderate or severe hepatic impairment provided that renal function is not impaired.

High-performance liquid chromatographic method for determination of DN-2327, a novel non-benzodiazepine anxiolytic, and/or its active metabolite in human plasma and urine

A sensitive and precise high-performance liquid chromatographic procedure has been developed for the determination of a new non-benzodiazepine anxiolytic agent, DN-2327 (I), and its pharmacologically active metabolite, MII (II), in human plasma and urine. Extraction of I, II, and the internal standard from plasma and urine samples were achieved using solid-phase extraction. Separation of the analytes was performed on a reversed-phase C18 column. The effluent was monitored with fluorescence detection at excitation and emission maxima of 328 and 367 nm, respectively. The work-up procedure was reproducible and recovered more than 92% of I and II from either plasma or urine. The chromatographic system for plasma and urine extracts allowed complete resolution of I and II from the internal standard with excellent selectivity. For each analyte, the lower detection limits were 0.1 and 1 ng/ml in plasma and urine, respectively. For each analyte, standard curves were linear in the ranges of 0.1-50 and 1-500 ng/ml in plasma and urine, respectively. The method was highly precise, with coefficients of variation for each analyte in quality controls that were generally below 7 and 5% for plasma and urine samples, respectively. The accuracy of the method was good with the deviations between added and calculated concentrations of each analyte being typically within +/- 10% and +/- 5.6% for plasma and urine samples, respectively. The stability of I and II in standard solutions, plasma and urine samples protected from laboratory light was excellent, with no evidence of degradation after 72 h at room temperature, five months at 4 degrees C, or three months at -20 degrees C.

Enantioselective determination of DN-2327, a novel non-benzodiazepine anxiolytic, and/or its active metabolite in human plasma and urine using high-performance liquid chromatography

A new rapid, specific and sensitive reversed-phase HPLC method has been developed for simultaneous measurement of the R- and S-enantiomers of DN-2327 (I), a novel non-benzodiazepine anxiolytic, and those of its pharmacologically active metabolite, MII (II), in human plasma or urine. Extraction of all the enantiomers and internal standard was achieved using solid-phase extraction on C8 columns. Resolution was achieved using a Chiral-AGP column with mobile phase comprising 6.5% (v/v) acetonitrile in 50 mM potassium acetate buffer, pH *q3 3.10, at typical flow-rates of 0.35 ml/min for plasma and 1.0 ml/min for urine assays. Fluorescence detection was employed using excitation and emission maxima of 328 and 367 nm, respectively. Analytes were well resolved and no interfering endogenous peaks were observed either from plasma or urine. Standard curves for urine were linear for concentrations up to 500 ng/ml for R- and S-II, with correlation coefficients higher than 0.994 and limit of quantitation (LOQ) of 1 ng/ml for each enantiomer. The LOQ in plasma was 0.1 ng/ml for each of the four enantiomers. The precision and accuracy of the method for the enantiomers of both I and II were good for plasma and urine with coefficients of variations typically within 10%. The stability of the R- and S-enantiomers of II and I in plasma and those of II in urine was excellent, with no evidence of degradation or interconversion during storage and handling.

HIV wasting syndrome in the United States

OBJECTIVE

To describe the characteristics of individuals > or = 13 years of age with HIV wasting syndrome in the United States and US territories.

DESIGN

Retrospective review of national AIDS case surveillance data.

METHODS

Data for the 147,225 individuals with AIDS reported to the Centers for Disease Control from 1 September 1987 to 31 August 1991 were reviewed. The frequency of HIV wasting syndrome and its association with demographic and exposure category variables and with other AIDS-indicator diseases were assessed.

RESULTS

A total of 10,525 (7.1%) had wasting syndrome as the only AIDS-indicator condition, and 15,726 (10.7%) had wasting syndrome plus at least one other AIDS-indicator condition. Patients with wasting syndrome as the only AIDS diagnosis were more likely to be female, to be black or Hispanic, and to have a mode of HIV exposure reported as injecting drug use, heterosexual contact, or transfusion/hemophilia. The proportion of AIDS patients reported with wasting syndrome varied by geographic distribution, ranging from 11% in the northeastern United States to 47% in Puerto Rico. The association between HIV wasting syndrome and Hispanic ethnicity was due to the much higher prevalence of wasting syndrome reported in Puerto Rican AIDS patients. The other AIDS-indicator conditions most strongly associated with wasting syndrome were isosporiasis, pulmonary candidiasis, esophageal candidiasis, HIV encephalopathy, chronic mucocutaneous herpes simplex, and coccidioidomycosis.

CONCLUSIONS

The association between HIV wasting syndrome and injecting drug use, and the significant racial/ethnic and geographic differences in prevalence of this AIDS diagnosis may reflect differences in diagnostic and reporting practices and/or access to medical care.

Acquired immunodeficiency syndrome in the United States associated with injecting drug use, 1981-1991

As of June 30, 1991, 182,834 AIDS cases in the United States had been reported to the Centers for Disease Control, of which 58,879 (32.2%) were associated with illicit drug use. Of these, 39,904 (70.0%) were in both women and heterosexual men reported as injecting drug users (IDUs), 11,823 (20.7%) in men who have sex with men who are also IDUs, 5,305 (9.3%) in sex partners of IDUs, and 1,847 (3.1%) in children whose mothers were either IDUs or sex partners of IDUs. From 1989 to 1990, the increase in the number of United States AIDS cases associated with IDU either directly or indirectly was higher in all regions compared with the Northeast. The highest percentage increases were in the South, U.S. territories, and the North Central. From 1989 to 1990, the percentage of AIDS cases attributed directly to IDU increased in women and men (15.3 and 5.9%, respectively); however, the increase in sex partners of IDUs was much larger (34.5% in men and 29.1% in women). Increases were also higher in sex partners of IDUs than in IDUs when compared by race/ethnicity and by region of residence. Because HIV can spread rapidly among IDUs and their sex partners, there is an immediate need for targeting effective HIV prevention messages to all IDUs and their sex partners in communities with high HIV infection rates.

Clarithromycin pharmacokinetics in healthy young and elderly volunteers

The pharmacokinetics of clarithromycin and its active 14(R)-hydroxy metabolite were assessed in 12 healthy young and 12 healthy elderly volunteers after oral administration of a multiple dose regimen of oral clarithromycin (500 mg every 12 hours for 5 doses). Plasma and urine clarithromycin and 14(R)-hydroxyclarithromycin concentrations were determined using high-performance liquid chromatography. The elderly subjects exhibited significantly elevated clarithromycin peak (Cmax) and trough (Cmin) plasma concentrations and area under the plasma concentration-time curve (AUC) compared with young subjects. In addition, the elderly group exhibited a significantly reduced apparent total body clearance (300 +/- 97 versus 476 +/- 112 mL/min, respectively) and renal clearance (CLR) (84 +/- 31 versus 168 +/- 35 mL/min, respectively). Similar results were noted for the 14(R)-hydroxy metabolite, with significantly elevated Cmax, Cmin, and AUC and reduced CLR in the elderly compared with the young group. Because the differences in parent and metabolite pharmacokinetic parameters were small and the increase in circulating drug concentrations was well tolerated (no increase in incidence or severity of adverse events), adjustments in clarithromycin dosing regimens may not be necessary solely on the basis of age.

Pharmacokinetics of a clarithromycin suspension in infants and children

The single- and multiple-dose pharmacokinetics of clarithromycin and its 14-(R)-hydroxylated metabolite in infants and children were studied after oral administration under fasting and nonfasting conditions. Drug absorption appeared to be rapid following a brief delay in its onset; the mean peak concentrations in plasma (Cmax) for clarithromycin were reached within about 3 h under both conditions. The mean Cmax for the parent drug were 3.59 and 4.58 micrograms/ml in single-dose fasting and nonfasting patients, and the respective Cmax for the metabolite were 1.19 and 1.26 micrograms/ml. Data indicate good absorption and no significant effects by food. There was no unusual accumulation in the area under the concentration-time curve and Cmax in the multiple-dose group.

Pharmacokinetics of clarithromycin, a new macrolide, after single ascending oral doses

The pharmacokinetics and safety of single ascending doses of clarithromycin (6-0-methylerythromycin A) were assessed in a placebo-controlled, double-blind, randomized trial with 39 healthy male volunteers. Subjects were randomized to receive single doses of either placebo or 100, 200, 400, 600, 800, or 1,200 mg of clarithromycin. Blood and urine collections were performed over the 24 h following administration of the test preparation. Biological specimens were analyzed for clarithromycin and 14(R)-hydroxyclarithromycin content by a high-performance liquid chromatographic technique. The pharmacokinetics of clarithromycin appeared to be dose dependent, with terminal disposition half-life ranging from 2.3 to 6.0 h and mean +/- standard deviation area under the concentration-versus-time curve from time 0 to infinity for plasma ranging from 1.67 +/- 0.48 to 3.72 +/- 1.26 mg/liter.h per 100-mg dose over the 100- to 1,200-mg dose range. Similar dose dependency was noted in the pharmacokinetics of the 14(R)-hydroxy metabolite. Mean urinary excretion of clarithromycin and its 14(R)-hydroxy metabolite ranged from 11.5 to 17.5% and 5.3 to 8.8% of the administered dose, respectively. Urinary excretion data and plasma metabolite/parent compound concentration ratio data suggested that capacity-limited formation of the active metabolite may account, at least in part, for the nonlinear pharmacokinetics of clarithromycin. No substantive dose-related trend was observed for the renal clearance of either compound. There were no clinically significant drug-related alterations in laboratory and nonlaboratory safety parameters. In addition, there was no significant difference between placebo and clarithromycin recipients in the incidence or severity of adverse events. Clarithromycin appears to be safe and well tolerated.

The reporting of HIV/AIDS deaths in women

OBJECTIVE

This study was undertaken to assess the completeness of vital statistics and case reports of acquired immunodeficiency syndrome (AIDS) in measuring human immunodeficiency virus (HIV)-related mortality in women 15 through 44 years of age.

METHODS

We used vital records to determine the number of deaths attributed to HIV infection and excess deaths due to causes that have increased in tandem with the HIV epidemic.

RESULTS

In 1988, among women 15 through 44 years of age, there were 1365 deaths with HIV infection listed as the underlying cause, 202 deaths with HIV infection listed as an associated cause, and 149 excess deaths due to conditions highly associated with HIV infection (subtotal = 1716). In addition, there were 780 excess deaths due to causes that may be related to HIV infection or illicit drug use (maximum estimate of HIV-related deaths = 2496). Of the deaths that occurred in 1988, 1532 were reported through AIDS surveillance (1668 deaths when adjusted for reporting delays).

CONCLUSIONS

Underlying-cause-of-death vital records and AIDS surveillance identified 55% to 80% and 67% to 97%, respectively, of HIV-related deaths in women 15 through 44 years of age in 1988. The wide ranges of these estimates reflect the potential role of both HIV infection and drug use in contributing to excess mortality.

Absolute bioavailability of clarithromycin after oral administration in humans

The absolute bioavailability of clarithromycin, a new macrolide antimicrobial agent, was assessed in a three-way, randomized, single-dose, crossover study conducted with 22 healthy volunteers, 19 of whom provided analyzable study data. The bioavailability parameters of two 250-mg oral tablet formulations were calculated with reference to an identical dose administered by intravenous infusion of the lactobionate salt. After adjustment for formulation potency, the mean absolute bioavailabilities of the two oral formulations were 52 and 55%, on the basis of the appearance of parent compound in the systemic circulation. Metabolite peak concentration and area under the plasma concentration-time curve data after oral dosing were generally greater than those after intravenous infusion, suggesting that marked first-pass metabolism of clarithromycin occurs after oral administration. Pharmacokinetic analysis of the parent drug and the active 14-hydroxy metabolite data suggests complete (or nearly complete) absorption of the drug after oral administration.