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Schackman BR, Haas DW, Park SS, Li XC, Freedberg KA. Cost-effectiveness of CYP2B6 genotyping to optimize efavirenz dosing in HIV clinical practice. Pharmacogenomics 2015; 16:2007-18. [PMID: 26607811 PMCID: PMC4832977 DOI: 10.2217/pgs.15.142] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
AIMS To assess the cost-effectiveness of CYP2B6 genotyping to guide efavirenz dosing for initial HIV therapy in the USA. METHODS We used the Cost-Effectiveness of Preventing AIDS Complications (CEPAC) microsimulation model to project quality-adjusted life expectancy and lifetime costs (2014 US dollars) for efavirenz-based HIV therapy with or without CYP2B6 genotyping. We assumed that with genotyping 60% of patients would be eligible to receive lower doses. RESULTS Current care without CYP2B6 genotyping has an incremental cost-effectiveness ratio >$100,000/QALY compared with genotype-guided dosing, even if lower dosing reduces efficacy. When we assumed generic efavirenz availability, conclusions were similar unless lower dosing reduces efficacy by 6% or more. CONCLUSION CYP2B6 genotyping can inform efavirenz dosing and decrease HIV therapy cost.
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Affiliation(s)
- Bruce R Schackman
- Department of Healthcare Policy & Research, Weill Cornell Medical College, New York, NY, USA
| | - David W Haas
- Department of Medicine, Division of Infectious Diseases, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Sanghee S Park
- Medical Practice Evaluation Center, Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - X Cynthia Li
- Medical Practice Evaluation Center, Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Kenneth A Freedberg
- Medical Practice Evaluation Center, Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA
- Department of Health Policy & Management, Harvard TH Chan School of Public Health, Boston, MA, USA
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52
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Meier BM, Gelpi A, Kavanagh MM, Forman L, Amon JJ. Employing human rights frameworks to realize access to an HIV cure. J Int AIDS Soc 2015; 18:20305. [PMID: 26568056 PMCID: PMC4644771 DOI: 10.7448/ias.18.1.20305] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2015] [Revised: 09/21/2015] [Accepted: 10/08/2015] [Indexed: 01/13/2023] Open
Abstract
INTRODUCTION The scale of the HIV pandemic - and the stigma, discrimination and violence that surrounded its sudden emergence - catalyzed a public health response that expanded human rights in principle and practice. In the absence of effective treatment, human rights activists initially sought to protect individuals at high risk of HIV infection. With advances in antiretroviral therapy, activists expanded their efforts under international law, advocating under the human right to health for individual access to treatment. DISCUSSION As a clinical cure comes within reach, human rights obligations will continue to play a key role in political and programmatic decision-making. Building upon the evolving development and implementation of the human right to health in the global response to HIV, we outline a human rights research agenda to prepare for HIV cure access, investigating the role of human rights law in framing 1) resource allocation, 2) international obligations, 3) intellectual property and 4) freedom from coercion. CONCLUSIONS The right to health is widely recognized as central to governmental, intergovernmental and non-governmental responses to the pandemic and critical both to addressing vulnerability to infection and to ensuring universal access to HIV prevention, treatment, care and support. While the advent of an HIV cure will raise new obligations for policymakers in implementing the right to health, the resolution of past debates surrounding HIV prevention and treatment may inform claims for universal access.
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Affiliation(s)
- Benjamin Mason Meier
- Department of Public Policy, University of North Carolina, Chapel Hill, NC, USA;
| | - Adriane Gelpi
- Edmond J. Safra Center for Ethics, Harvard University, Cambridge, MA, USA
| | - Matthew M Kavanagh
- Department of Political Science, Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
| | - Lisa Forman
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - Joseph J Amon
- Health and Human Rights Division, Human Rights Watch, New York, NY, USA
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Knowlton AR, Mitchell MM, Robinson AC, Nguyen TQ, Isenberg S, Denison J. Informal HIV Caregiver Proxy Reports of Care Recipients' Treatment Adherence: Relationship Factors Associated with Concordance with Recipients' Viral Suppression. AIDS Behav 2015; 19:2123-9. [PMID: 26036463 DOI: 10.1007/s10461-015-1092-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
To explore the role of informal caregivers in adherence, we compared adherence reports by caregivers to those of care recipients. We identified individual-level and relationship factors associated with agreement between caregivers' reports of recipients' adherence and assessed viral suppression. Participants were care recipients, who were on ART and had ever injected drugs, and their caregivers (N = 258 dyads). Nearly three-fourths of caregivers' reports of recipients' ART adherence agreed with recipients' viral suppression status. Agreement was associated with recipient age and expressing affection or gratitude to the caregiver, caregiver's having been close to someone who died of HIV/AIDS, and caregiver's fear of caregiving-related HIV (re)infection, while it was negatively associated with recipient's limited physical functioning. Our findings support the utility of caregiver proxy reports of care recipients' ART adherence and suggest ways to identify and promote HIV caregiver attention to and support of this vulnerable population's ART adherence.
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Affiliation(s)
- Amy R Knowlton
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, 624 North Broadway, Room 745, Baltimore, MD, 21205, USA.
| | - Mary M Mitchell
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, 624 North Broadway, Room 745, Baltimore, MD, 21205, USA
| | - Allysha C Robinson
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, 624 North Broadway, Room 745, Baltimore, MD, 21205, USA
| | - Trang Q Nguyen
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, 624 North Broadway, Room 745, Baltimore, MD, 21205, USA
| | - Sarina Isenberg
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, 624 North Broadway, Room 745, Baltimore, MD, 21205, USA
| | - Julie Denison
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe St, Baltimore, MD, USA
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54
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Kashima J, Okuma Y, Watanabe K, Ajisawa A, Hishima T. Cellulitis-like symptoms manifested by bone metastasis of lung cancer in a patient living with human immunodeficiency virus. Int J STD AIDS 2015; 27:912-6. [PMID: 26404113 DOI: 10.1177/0956462415606014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2015] [Accepted: 08/21/2015] [Indexed: 11/16/2022]
Abstract
Human immunodeficiency virus (HIV)-infected patients are at a high risk of cancer compared with the general population. As the use of antiretroviral therapy (ART) has increased, non-AIDS-defining cancers have also increased in the past decade. A 61-year-old man with HIV infection on ART developed a painful, erythematous and oedematous lower left leg and an associated fever. He was initially treated with antibiotics for cellulitis but there was no improvement, which warranted further investigation. A translucent lesion was found by X-ray imaging and bone scintigraphy showed bone metastasis from a primary adenocarcinoma of the lung, documented by chest computed tomography and an axillary lymph node biopsy. The patient died three months after the diagnosis despite undergoing chemotherapy. This case demonstrates that physicians should consider metastatic malignancies as a differential diagnoses for diverse skin changes in HIV-infected patients.
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Affiliation(s)
- Jumpei Kashima
- Department of Thoracic Oncology and Respiratory Medicine, Tokyo Metropolitan Cancer and Infectious diseases Center Komagome Hospital, Tokyo, Japan
| | - Yusuke Okuma
- Department of Thoracic Oncology and Respiratory Medicine, Tokyo Metropolitan Cancer and Infectious diseases Center Komagome Hospital, Tokyo, Japan Division of Oncology, Research Center for Medical Sciences, The Jikei University School of Medicine, Tokyo, Japan
| | - Kageaki Watanabe
- Department of Thoracic Oncology and Respiratory Medicine, Tokyo Metropolitan Cancer and Infectious diseases Center Komagome Hospital, Tokyo, Japan
| | - Atushi Ajisawa
- Toshima Hospital, Tokyo Metropolitan Health and Medical Treatment Corporation, Tokyo, Japan
| | - Tsunekazu Hishima
- Department of Pathology, Tokyo Metropolitan Cancer and Infectious diseases Center Komagome Hospital, Tokyo, Japan
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Abstract
Human immunodeficiency virus (HIV) is a disease that affects 1 million patients in the United States. Many excellent drug regimens exist that effectively suppress the viral load and improve immune function, but there are consequences of long-term antiviral therapy. In addition, patients with HIV tend to have much higher rates of chronic disease, substance abuse, and cancer. Thus, while expert care in the treatment of HIV remains critical, the skill set of a primary care provider in the prevention, detection, and management of acute and chronic illness is vital to the care of the HIV patient.
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Affiliation(s)
- Fred R Buckhold
- Internal Medicine Residency Training Program, Division of General Internal Medicine, Department of Medicine, Saint Louis University School of Medicine, 1402 South Grand Boulevard, FDT 14th Floor, Saint Louis, MO 63104, USA.
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56
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Ebor M, Murray A, Gaul Z, Sutton M. HIV Awareness and Knowledge among Viewers of a Documentary Film about HIV among Racial- or Ethnic-Minority Older Adults. HEALTH & SOCIAL WORK 2015; 40:217-224. [PMID: 26285361 DOI: 10.1093/hsw/hlv041] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
A documentary film on HIV was developed based on social cognitive theory and entertainment educational methods in an effort to increase awareness and encourage protective behavior change related to HIV among older adults. The documentary includes perspectives from racial- or ethnic-minority older adults who are living with HIV and those of health care providers, and was screened in several venues. Authors of this article conducted thematic content analysis of anonymous, written, open-ended responses from 341 film viewers (clinicians and laypeople) who described what they learned about HIV after viewing the film. Four key themes emerged from the analysis: (1) increased awareness about the epidemiology of HIV among older, minority groups and about sexuality among older people; (2) improved general HIV knowledge, including risk reduction strategies and details about HIV testing; (3) awareness of lack of sexual health education among health care providers, and that a call to action is needed; and (4) awareness that HIV reinfection can occur in certain circumstances with people who are already infected. Findings suggest that an educational documentary can be used to effectively increase awareness and knowledge about the impact of HIV among minority older adults, and may also encourage HIV prevention action steps by providers.
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Antiretroviral Therapy Adherence and Use of an Electronic Shared Medical Record Among People Living with HIV. AIDS Behav 2015; 19 Suppl 2:177-85. [PMID: 25572829 DOI: 10.1007/s10461-014-0982-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Electronic shared medical records (SMR) are emerging healthcare technologies that allow patients to engage in their healthcare by communicating with providers, refilling prescriptions, scheduling appointments, and viewing portions of medical records. We conducted a pre-post cohort study of HIV-positive adults who used and did not use SMR in two integrated healthcare systems. We compared the difference in antiretroviral refill adherence between SMR users and age- and sex-frequency matched non-users from the 12-month period prior to SMR useto the 12-month period starting 6 months after initiation of SMR use. High adherence was maintained among SMR users (change = -0.11 %) but declined among non-users (change = -2.05 %; p = 0.003). Among SMR users, there was a steady improvement in adherence as monthly frequency of SMR use increased (p = 0.009). SMR use, particularly more frequent use, is associated with maintaining high adherence and non-use is associated with declines in adherence over time among patients with access to these online services.
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58
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Houston E, Osborn A. THE USE OF SELF-MANAGED TREATMENT STRATEGIES IN A PREDOMINANTLY LOW-INCOME, AFRICAN-AMERICAN SAMPLE OF WOMEN LIVING WITH HIV. Psychol Rep 2015; 116:861-9. [PMID: 25933048 DOI: 10.2466/13.pr0.116k27w8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
While low-income and ethnic minority women represent a growing proportion of new HIV cases in the United States, little is known about how they manage their antiretroviral medication regimens. Using a predominantly low-income, African-American sample (N = 85), this study examined medication self-management strategies among HIV seropositive women undergoing antiretroviral therapy in a major metropolitan area. Most study participants (95%; n = 81) reported employing a specific medication management strategy during the previous week. Pillboxes, use of daily activities, and receiving reminders from another person were the most common strategies. Most participants (80.2%) employed two or more strategies. Age, education, and motivation were associated with alarm, pillbox, and visual aid usage.
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Affiliation(s)
- Eric Houston
- 1 Illinois Institute of Technology, Chicago, Illinois
| | - Amanda Osborn
- 1 Illinois Institute of Technology, Chicago, Illinois
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Schackman BR, Fleishman JA, Su AE, Berkowitz BK, Moore RD, Walensky RP, Becker JE, Voss C, Paltiel AD, Weinstein MC, Freedberg KA, Gebo KA, Losina E. The lifetime medical cost savings from preventing HIV in the United States. Med Care 2015; 53:293-301. [PMID: 25710311 PMCID: PMC4359630 DOI: 10.1097/mlr.0000000000000308] [Citation(s) in RCA: 82] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Enhanced HIV prevention interventions, such as preexposure prophylaxis for high-risk individuals, require substantial investments. We sought to estimate the medical cost saved by averting 1 HIV infection in the United States. METHODS We estimated lifetime medical costs in persons with and without HIV to determine the cost saved by preventing 1 HIV infection. We used a computer simulation model of HIV disease and treatment (CEPAC) to project CD4 cell count, antiretroviral treatment status, and mortality after HIV infection. Annual medical cost estimates for HIV-infected persons, adjusted for age, sex, race/ethnicity, and transmission risk group, were from the HIV Research Network (range, $1854-$4545/mo) and for HIV-uninfected persons were from the Medical Expenditure Panel Survey (range, $73-$628/mo). Results are reported as lifetime medical costs from the US health system perspective discounted at 3% (2012 USD). RESULTS The estimated discounted lifetime cost for persons who become HIV infected at age 35 is $326,500 (60% for antiretroviral medications, 15% for other medications, 25% nondrug costs). For individuals who remain uninfected but at high risk for infection, the discounted lifetime cost estimate is $96,700. The medical cost saved by avoiding 1 HIV infection is $229,800. The cost saved would reach $338,400 if all HIV-infected individuals presented early and remained in care. Cost savings are higher taking into account secondary infections avoided and lower if HIV infections are temporarily delayed rather than permanently avoided. CONCLUSIONS The economic value of HIV prevention in the United States is substantial given the high cost of HIV disease treatment.
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Affiliation(s)
- Bruce R Schackman
- *Department of Healthcare Policy and Research, Weill Cornell Medical College, New York, NY †Agency for Healthcare Research and Quality, Rockville, MD ‡Division of General Internal Medicine §Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA ∥Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD ¶Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA #Center for AIDS Research, Harvard University, Cambridge, MA **Division of Infectious Disease, Brigham and Women's Hospital, Boston, MA ††Department of Health Policy and Management, Yale School of Public Health, New Haven, CT ‡‡Department of Health Policy and Management, Harvard School of Public Health, Boston, MA §§Department of Epidemiology, Boston University School of Public Health, Boston, MA ∥∥Department of Orthopedic Surgery, Brigham and Women's Hospital, Boston, MA ¶¶Department of Biostatistics, Boston University School of Public Health, Boston, MA
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60
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Palma A, Lounsbury DW, Messer L, Quinlivan EB. Patterns of HIV service use and HIV viral suppression among patients treated in an academic infectious diseases clinic in North Carolina. AIDS Behav 2015; 19:694-703. [PMID: 25240628 DOI: 10.1007/s10461-014-0907-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Irregular participation in HIV medical care hinders HIV RNA suppression and impacts health among people living with HIV. Cluster analysis of clinical data from 1,748 patients attending a large academic medical center yielded three HIV service usage patterns, namely: 'engaged in care', 'sporadic care', and 'frequent use'. Patients 'engaged in care' exhibited most consistent retention (on average, >88 % of each patient's observation years had ≥2 visits 90 days apart), annualized visit use (2.9 mean visits/year) and viral suppression (>73 % HIV RNA tests <400 c/mL). Patients in 'sporadic care' demonstrated lower retention (46-52 %), visit use (1.7 visits/year) and viral suppression (56 % <400 c/mL). Patients with 'frequent use' (5.2 visits/year) had more inpatient and emergency visits. Female, out-of-state residence, low attendance during the first observation year and detectable first-observed HIV RNA were early predictors of subsequent service usage. Patients 'engaged in care' were more likely to have HIV RNA <400 than those receiving sporadic care. Results confirm earlier findings that under-utilization of services predicts poorer viral suppression and health outcomes and support recommendations for 2-3 visits/year.
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Affiliation(s)
- Anton Palma
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY, USA,
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61
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In vitro drug combination studies of Letermovir (AIC246, MK-8228) with approved anti-human cytomegalovirus (HCMV) and anti-HIV compounds in inhibition of HCMV and HIV replication. Antimicrob Agents Chemother 2015; 59:3140-8. [PMID: 25779572 DOI: 10.1128/aac.00114-15] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2015] [Accepted: 03/06/2015] [Indexed: 12/13/2022] Open
Abstract
Despite modern prevention and treatment strategies, human cytomegalovirus (HCMV) remains a common opportunistic pathogen associated with serious morbidity and mortality in immunocompromised individuals, such as transplant recipients and AIDS patients. All drugs currently licensed for the treatment of HCMV infection target the viral DNA polymerase and are associated with severe toxicity issues and the emergence of drug resistance. Letermovir (AIC246, MK-8228) is a new anti-HCMV agent in clinical development that acts via a novel mode of action and has demonstrated anti-HCMV activity in vitro and in vivo. For the future, drug combination therapies, including letermovir, might be indicated under special medical conditions, such as the emergence of multidrug-resistant virus strains in transplant recipients or in HCMV-HIV-coinfected patients. Accordingly, knowledge of the compatibility of letermovir with other HCMV or HIV antivirals is of medical importance. Here, we evaluated the inhibition of HCMV replication by letermovir in combination with all currently approved HCMV antivirals using cell culture checkerboard assays. In addition, the effects of letermovir on the antiviral activities of selected HIV drugs, and vice versa, were analyzed. Using two different mathematical techniques to analyze the experimental data, (i) additive effects were observed for the combination of letermovir with anti-HCMV drugs and (ii) no interaction was found between letermovir and anti-HIV drugs. Since none of the tested drug combinations significantly antagonized letermovir efficacy (or vice versa), our findings suggest that letermovir may offer the potential for combination therapy with the tested HCMV and HIV drugs.
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62
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Clark H, Surendera Babu A, Harris S, Hardnett F. HIV-Related Mortality Among Adults (≥ 18 years) of Various Hispanic or Latino Subgroups--United States, 2006-2010. J Racial Ethn Health Disparities 2015; 2:53-61. [PMID: 26863241 PMCID: PMC5381268 DOI: 10.1007/s40615-014-0047-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2014] [Revised: 07/29/2014] [Accepted: 08/22/2014] [Indexed: 10/24/2022]
Abstract
Hispanics or Latinos residing in the USA are disproportionately affected by HIV when compared to whites. Health outcomes for Hispanics or Latinos diagnosed with HIV infection may vary by Hispanic or Latino subgroup. We analyzed national mortality data from the National Center for Health Statistics for the years 2006 to 2010 to examine differences in HIV-related mortality among Hispanics or Latinos by sociodemographic factors and by Hispanic or Latino subgroup. After adjusting for age, HIV-related death rates per 100,000 population were highest among Hispanics or Latinos who were male (45.6, 95 % confidence interval [CI], 44.4 to 46.9) compared to female (12.0, 95 % CI 11.4 to 12.6), or resided in the Northeast (75.1, 95 % CI 72.2 to 77.9) compared to other US regions at the time of death. The age-adjusted HIV-related death rate was highest among Puerto Ricans (100.9, 95 % CI 97.0 to 104.8) and lowest among Mexicans (16.9, 95 % CI 16.2 to 17.6). Among all deaths, the proportion of HIV-related deaths was more than four times as high among Puerto Ricans (adjusted prevalence ratio = 4.3, 95 % CI 4.1 to 4.5) compared to Mexicans. To ensure better health outcomes for Hispanics or Latinos living with HIV in the USA, medical care and treatment programs should be adapted to address the needs of various Hispanic or Latino subgroups.
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Affiliation(s)
- Hollie Clark
- Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, 1600 Clifton Rd. NE, MS E47, Atlanta, GA, 30329, USA.
| | | | | | - Felicia Hardnett
- Division of HIV/AIDS Prevention, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, 1600 Clifton Rd., NE, MS E48, Atlanta, GA, 30329, USA
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63
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Lourenço L, Samji H, Nohpal A, Chau W, Colley G, Lepik K, Barrios R, Lima V, Hogg RS, Montaner J, Kesselring S, Moore DM. Declines in highly active antiretroviral therapy initiation at CD4 cell counts ≤ 200 cells/μL and the contribution of diagnosis of HIV at CD4 cell counts ≤ 200 cells/μL in British Columbia, Canada. HIV Med 2015; 16:337-45. [PMID: 25721157 DOI: 10.1111/hiv.12212] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/09/2014] [Indexed: 12/31/2022]
Abstract
OBJECTIVES The aim of the study was to examine trends in initiating highly active antiretroviral therapy (HAART) with a CD4 count ≤ 200 cells/μL and the contribution of having a CD4 count ≤ 200 cells/μL at the time of diagnosis to these trends, in British Columbia (BC), Canada. METHODS We included in the analysis treatment-naïve BC residents aged ≥ 19 years who initiated HAART from 2003 to 2012. Participants were classified as follows: Group 1: diagnosed and initiated HAART with a CD4 count > 200 cells/μL; Group 2: diagnosed with a CD4 count > 200 cells/μL and initiated HAART with a CD4 count ≤ 200 cells/μL; and Group 3: diagnosed and initiated HAART with a CD4 count ≤ 200 cells/μL. We measured trends in initiating HAART with a CD4 count ≤ 200 cells/μL and used logistic regression models to measure factors associated with initiating HAART with a CD4 count ≤ 200 cells/μL, stratified by having a CD4 count ≤ 200 cells/μL or > 200 cells/μL at the time of diagnosis. RESULTS Between 2003 and 2012, 3506 BC residents initiated HAART. Of these, 44% (1558 of 3506) initiated HAART with a CD4 count ≤ 200 cells/μL. This proportion declined from 69% (198 of 287) in 2003 to 21% (81 of 330) in 2012 (P < 0.001). The proportion of those in Group 3 increased from 49% (97 of 198) in 2003 to 69% (56 of 81) in 2012 (P < 0.001). Overall, 56% (1948), 22% (776) and 22% (782) made up Groups 1, 2, and 3, respectively. In adjusted analyses, seeing a specialist was significantly associated with being in Group 3. Using injection drugs and seeing a specialist were associated with being in Group 2. CONCLUSIONS In recent years, among individuals who ever initiated HAART in BC, being diagnosed with low CD4 cell counts has become a greater contributor to initiating HAART with low CD4 cell counts.
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Affiliation(s)
- L Lourenço
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada
| | - H Samji
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada
| | - A Nohpal
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada
| | - W Chau
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada
| | - G Colley
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada
| | - K Lepik
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada
| | - R Barrios
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada
| | - V Lima
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada.,Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - R S Hogg
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada.,Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada
| | - Jsg Montaner
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada.,Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - S Kesselring
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada
| | - D M Moore
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada.,Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
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Ascertainment and verification of end-stage renal disease and end-stage liver disease in the north american AIDS cohort collaboration on research and design. AIDS Res Treat 2015; 2015:923194. [PMID: 25789171 PMCID: PMC4350581 DOI: 10.1155/2015/923194] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2014] [Accepted: 01/16/2015] [Indexed: 02/08/2023] Open
Abstract
The burden of HIV disease has shifted from traditional AIDS-defining illnesses to serious non-AIDS-defining comorbid conditions. Research aimed at improving HIV-related comorbid disease outcomes requires well-defined, verified clinical endpoints. We developed methods to ascertain and verify end-stage renal disease (ESRD) and end-stage liver disease (ESLD) and validated screening algorithms within the largest HIV cohort collaboration in North America (NA-ACCORD). Individuals who screened positive among all participants in twelve cohorts enrolled between January 1996 and December 2009 underwent medical record review to verify incident ESRD or ESLD using standardized protocols. We randomly sampled 6% of contributing cohorts to determine the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of ESLD and ESRD screening algorithms in a validation subcohort. Among 43,433 patients screened for ESRD, 822 screened positive of which 620 met clinical criteria for ESRD. The algorithm had 100% sensitivity, 99% specificity, 82% PPV, and 100% NPV for ESRD. Among 41,463 patients screened for ESLD, 2,024 screened positive of which 645 met diagnostic criteria for ESLD. The algorithm had 100% sensitivity, 95% specificity, 27% PPV, and 100% NPV for ESLD. Our methods proved robust for ascertainment of ESRD and ESLD in persons infected with HIV.
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65
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Heaton RK, Franklin DR, Deutsch R, Letendre S, Ellis RJ, Casaletto K, Marquine MJ, Woods SP, Vaida F, Atkinson JH, Marcotte TD, McCutchan JA, Collier AC, Marra CM, Clifford DB, Gelman BB, Sacktor N, Morgello S, Simpson DM, Abramson I, Gamst AC, Fennema-Notestine C, Smith DM, Grant I. Neurocognitive change in the era of HIV combination antiretroviral therapy: the longitudinal CHARTER study. Clin Infect Dis 2015; 60:473-80. [PMID: 25362201 PMCID: PMC4303775 DOI: 10.1093/cid/ciu862] [Citation(s) in RCA: 285] [Impact Index Per Article: 31.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2014] [Accepted: 08/19/2014] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Human immunodeficiency virus (HIV)-associated neurocognitive disorders (HAND) can show variable clinical trajectories. Previous longitudinal studies of HAND typically have been brief, did not use adequate normative standards, or were conducted in the context of a clinical trial, thereby limiting our understanding of incident neurocognitive (NC) decline and recovery. METHODS We investigated the incidence and predictors of NC change over 16-72 (mean, 35) months in 436 HIV-infected participants in the CNS HIV Anti-Retroviral Therapy Effects Research cohort. Comprehensive laboratory, neuromedical, and NC assessments were obtained every 6 months. Published, regression-based norms for NC change were used to generate overall change status (decline vs stable vs improved) at each study visit. Survival analysis was used to examine the predictors of time to NC change. RESULTS Ninety-nine participants (22.7%) declined, 265 (60.8%) remained stable, and 72 (16.5%) improved. In multivariable analyses, predictors of NC improvements or declines included time-dependent treatment status and indicators of disease severity (current hematocrit, albumin, total protein, aspartate aminotransferase), and baseline demographics and estimated premorbid intelligence quotient, non-HIV-related comorbidities, current depressive symptoms, and lifetime psychiatric diagnoses (overall model P < .0001). CONCLUSIONS NC change is common in HIV infection and appears to be driven by a complex set of risk factors involving HIV disease, its treatment, and comorbid conditions.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - J. Hampton Atkinson
- University of California, San Diego
- Veterans Affairs San Diego Healthcare System, California
| | | | | | | | | | | | | | - Ned Sacktor
- Johns Hopkins University, Baltimore, Maryland
| | - Susan Morgello
- Icahn School of Medicine at Mount Sinai, New York, New York
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Morris BL, Scott CA, Wilkin TJ, Sax PE, Gulick RM, Freedberg KA, Schackman BR. Cost-effectiveness of Adding an Agent That Improves Immune Responses to Initial Antiretroviral Therapy (ART) in HIV-Infected Patients: Guidance for Drug Development. HIV CLINICAL TRIALS 2015. [DOI: 10.1310/hct1301-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Quinlivan EB, Fletcher J, Eastwood EA, Blank AE, Verdecias N, Roytburd K. Health status of HIV-infected women entering care: baseline medical findings from the women of color initiative. AIDS Patient Care STDS 2015; 29 Suppl 1:S11-9. [PMID: 25561306 PMCID: PMC4283073 DOI: 10.1089/apc.2014.0277] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
The WOC Initiative is a prospective study of 921 women of color (WOC) entering HIV care at nine (three rural, six urban) sites across the US. A baseline interview was performed that included self-reported limitation(s) in activity, health conditions, and the CDC's health-related quality of life measures (Healthy Days). One-third of the WOC reported limiting an activity because of illness or a health condition and those with an activity limitation reported 13 physically and 14 mentally unhealthy days/month, compared with 5 physically and 9 mentally unhealthy days/month in the absence of an activity limitation. Age was associated with a three- to fourfold increased risk of an activity limitation but only for WOC in the urban sites. Diabetes was associated with a threefold increased risk of a limitation among women at rural sites. Cardiac disease was associated with a six- to sevenfold increased risk of an activity limitation for both urban and rural WOC. HIV+ WOC reported more physically and mentally unhealthy days than the general US female population even without an activity limitation. Prevention and treatment of diabetes and cardiovascular disease will need to be a standard part of HIV care to promote the long-term health and HRQOL for HIV-infected WOC.
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Affiliation(s)
- E Byrd Quinlivan
- 1 Institute for Global Health and Infectious Diseases, University of North Carolina at Chapel Hill , Chapel Hill, North Carolina
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68
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Abstract
For the first decade and a half after the Human Immunodeficiency Virus (HIV) was first identified, the prognosis for most people infected with HIV was quite poor. Life insurance companies responded accordingly and insurance laboratories developed new means to test for the infection. However, it is now clear that people with HIV infection are living longer and that the majority of deaths occurring among those on treatment are now no longer due to AIDS-defining illnesses. This review examines the results of selected studies which analyzed mortality outcomes in those with HIV infection, the many factors which influence those outcomes, and the limitations in the data and in their applicability to an insurance population.
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69
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High levels of heterogeneity in the HIV cascade of care across different population subgroups in British Columbia, Canada. PLoS One 2014; 9:e115277. [PMID: 25541682 PMCID: PMC4277297 DOI: 10.1371/journal.pone.0115277] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2014] [Accepted: 11/23/2014] [Indexed: 01/22/2023] Open
Abstract
Background The HIV cascade of care (cascade) is a comprehensive tool which identifies attrition along the HIV care continuum. We executed analyses to explicate heterogeneity in the cascade across key strata, as well as identify predictors of attrition across stages of the cascade. Methods Using linked individual-level data for the population of HIV-positive individuals in BC, we considered the 2011 calendar year, including individuals diagnosed at least 6 months prior, and excluding individuals that died or were lost to follow-up before January 1st, 2011. We defined five stages in the cascade framework: HIV ‘diagnosed’, ‘linked’ to care, ‘retained’ in care, ‘on HAART’ and virologically ‘suppressed’. We stratified the cascade by sex, age, risk category, and regional health authority. Finally, multiple logistic regression models were built to predict attrition across each stage of the cascade, adjusting for stratification variables. Results We identified 7621 HIV diagnosed individuals during the study period; 80% were male and 5% were <30, 17% 30–39, 37% 40–49 and 40% were ≥50 years. Of these, 32% were MSM, 28% IDU, 8% MSM/IDU, 12% heterosexual, and 20% other. Overall, 85% of individuals ‘on HAART’ were ‘suppressed’; however, this proportion ranged from 60%–93% in our various stratifications. Most individuals, in all subgroups, were lost between the stages: ‘linked’ to ‘retained’ and ‘on HAART’ to ‘suppressed’. Subgroups with the highest attrition between these stages included females and individuals <30 years (regardless of transmission risk group). IDUs experienced the greatest attrition of all subgroups. Logistic regression results found extensive statistically significant heterogeneity in attrition across the cascade between subgroups and regional health authorities. Conclusions We found that extensive heterogeneity in attrition existed across subgroups and regional health authorities along the HIV cascade of care in B.C., Canada. Our results provide critical information to optimize engagement in care and health service delivery.
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70
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Fennie KP, Lutfi K, Maddox LM, Lieb S, Trepka MJ. Influence of residential segregation on survival after AIDS diagnosis among non-Hispanic blacks. Ann Epidemiol 2014; 25:113-9, 119.e1. [PMID: 25542342 DOI: 10.1016/j.annepidem.2014.11.023] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2014] [Revised: 08/29/2014] [Accepted: 11/04/2014] [Indexed: 12/15/2022]
Abstract
PURPOSE Non-Hispanic blacks (NHBs) are disproportionately affected by the AIDS epidemic. With the advent of highly active antiretroviral therapy (HAART), survival after AIDS diagnosis has increased dramatically, yet survival among NHBs is shorter compared with non-Hispanic whites. Racial residential segregation may be an important factor influencing observed racial disparities in survival. METHODS We linked data on 30,813 NHBs from the Florida Department of Health HIV/AIDS Reporting system (1993-2004) with death records and applied segregation indices and poverty levels to the data. Weighted Cox models were used to examine the association between segregation measured on five dimensions and survival, controlling for demographic factors, clinical factors, and area-level poverty. Analyses were stratified by pre-HAART (1993-1995), early HAART (1996-1998), and late-HAART (1999-2004) eras. RESULTS In the late-HAART era, adjusting for area-level poverty, segregation remained a significant predictor of survival on two dimensions: Concentration (hazard ratio, 1.32; 95% confidence interval, 1.13-1.56) and centralization (hazard ratio, 1.44; 95% confidence interval, 1.12-1.84). Area-level poverty was an independent predictor of survival. CONCLUSIONS These findings suggest that certain dimensions of segregation and poverty are associated with survival after AIDS diagnosis.
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Affiliation(s)
- Kristopher P Fennie
- Department of Epidemiology, Robert Stempel College of Public Health and Social Work, Florida International University, Miami.
| | - Khaleeq Lutfi
- Department of Epidemiology, Robert Stempel College of Public Health and Social Work, Florida International University, Miami
| | - Lorene M Maddox
- Florida Consortium for HIV/AIDS Research/The AIDS Institute, Tampa
| | - Spencer Lieb
- HIV/AIDS Section, Florida Department of Health, Tallahassee
| | - Mary Jo Trepka
- Department of Epidemiology, Robert Stempel College of Public Health and Social Work, Florida International University, Miami
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71
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Del Prete GQ, Shoemaker R, Oswald K, Lara A, Trubey CM, Fast R, Schneider DK, Kiser R, Coalter V, Wiles A, Wiles R, Freemire B, Keele BF, Estes JD, Quiñones OA, Smedley J, Macallister R, Sanchez RI, Wai JS, Tan CM, Alvord WG, Hazuda DJ, Piatak M, Lifson JD. Effect of suberoylanilide hydroxamic acid (SAHA) administration on the residual virus pool in a model of combination antiretroviral therapy-mediated suppression in SIVmac239-infected indian rhesus macaques. Antimicrob Agents Chemother 2014; 58:6790-806. [PMID: 25182644 PMCID: PMC4249371 DOI: 10.1128/aac.03746-14] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2014] [Accepted: 08/25/2014] [Indexed: 11/20/2022] Open
Abstract
Nonhuman primate models are needed for evaluations of proposed strategies targeting residual virus that persists in HIV-1-infected individuals receiving suppressive combination antiretroviral therapy (cART). However, relevant nonhuman primate (NHP) models of cART-mediated suppression have proven challenging to develop. We used a novel three-class, six-drug cART regimen to achieve durable 4.0- to 5.5-log reductions in plasma viremia levels and declines in cell-associated viral RNA and DNA in blood and tissues of simian immunodeficiency virus SIVmac239-infected Indian-origin rhesus macaques, then evaluated the impact of treatment with the histone deacetylase inhibitor (HDACi) suberoylanilide hydroxamic acid (SAHA; Vorinostat) on the residual virus pool. Ex vivo SAHA treatment of CD4(+) T cells obtained from cART-suppressed animals increased histone acetylation and viral RNA levels in culture supernatants. cART-suppressed animals each received 84 total doses of oral SAHA. We observed SAHA dose-dependent increases in acetylated histones with evidence for sustained modulation as well as refractoriness following prolonged administration. In vivo virologic activity was demonstrated based on the ratio of viral RNA to viral DNA in peripheral blood mononuclear cells, a presumptive measure of viral transcription, which significantly increased in SAHA-treated animals. However, residual virus was readily detected at the end of treatment, suggesting that SAHA alone may be insufficient for viral eradication in the setting of suppressive cART. The effects observed were similar to emerging data for repeat-dose SAHA treatment of HIV-infected individuals on cART, demonstrating the feasibility, utility, and relevance of NHP models of cART-mediated suppression for in vivo assessments of AIDS virus functional cure/eradication approaches.
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Affiliation(s)
- Gregory Q Del Prete
- AIDS and Cancer Virus Program, Leidos Biomedical Research, Inc., Frederick National Laboratory for Cancer Research, Frederick, Maryland, USA
| | - Rebecca Shoemaker
- AIDS and Cancer Virus Program, Leidos Biomedical Research, Inc., Frederick National Laboratory for Cancer Research, Frederick, Maryland, USA
| | - Kelli Oswald
- AIDS and Cancer Virus Program, Leidos Biomedical Research, Inc., Frederick National Laboratory for Cancer Research, Frederick, Maryland, USA
| | - Abigail Lara
- AIDS and Cancer Virus Program, Leidos Biomedical Research, Inc., Frederick National Laboratory for Cancer Research, Frederick, Maryland, USA
| | - Charles M Trubey
- AIDS and Cancer Virus Program, Leidos Biomedical Research, Inc., Frederick National Laboratory for Cancer Research, Frederick, Maryland, USA
| | - Randy Fast
- AIDS and Cancer Virus Program, Leidos Biomedical Research, Inc., Frederick National Laboratory for Cancer Research, Frederick, Maryland, USA
| | - Douglas K Schneider
- AIDS and Cancer Virus Program, Leidos Biomedical Research, Inc., Frederick National Laboratory for Cancer Research, Frederick, Maryland, USA
| | - Rebecca Kiser
- AIDS and Cancer Virus Program, Leidos Biomedical Research, Inc., Frederick National Laboratory for Cancer Research, Frederick, Maryland, USA
| | - Vicky Coalter
- AIDS and Cancer Virus Program, Leidos Biomedical Research, Inc., Frederick National Laboratory for Cancer Research, Frederick, Maryland, USA
| | - Adam Wiles
- AIDS and Cancer Virus Program, Leidos Biomedical Research, Inc., Frederick National Laboratory for Cancer Research, Frederick, Maryland, USA
| | - Rodney Wiles
- AIDS and Cancer Virus Program, Leidos Biomedical Research, Inc., Frederick National Laboratory for Cancer Research, Frederick, Maryland, USA
| | - Brandi Freemire
- AIDS and Cancer Virus Program, Leidos Biomedical Research, Inc., Frederick National Laboratory for Cancer Research, Frederick, Maryland, USA
| | - Brandon F Keele
- AIDS and Cancer Virus Program, Leidos Biomedical Research, Inc., Frederick National Laboratory for Cancer Research, Frederick, Maryland, USA
| | - Jacob D Estes
- AIDS and Cancer Virus Program, Leidos Biomedical Research, Inc., Frederick National Laboratory for Cancer Research, Frederick, Maryland, USA
| | - Octavio A Quiñones
- Statistical Consulting, Data Management Services, Inc., Frederick, Maryland, USA
| | - Jeremy Smedley
- Laboratory Animal Sciences Program, Leidos Biomedical Research, Inc., Frederick National Laboratory for Cancer Research, Frederick, Maryland, USA
| | - Rhonda Macallister
- Laboratory Animal Sciences Program, Leidos Biomedical Research, Inc., Frederick National Laboratory for Cancer Research, Frederick, Maryland, USA
| | | | - John S Wai
- Merck Research Labs, West Point, Pennsylvania, USA
| | | | - W Gregory Alvord
- Statistical Consulting, Data Management Services, Inc., Frederick, Maryland, USA
| | | | - Michael Piatak
- AIDS and Cancer Virus Program, Leidos Biomedical Research, Inc., Frederick National Laboratory for Cancer Research, Frederick, Maryland, USA
| | - Jeffrey D Lifson
- AIDS and Cancer Virus Program, Leidos Biomedical Research, Inc., Frederick National Laboratory for Cancer Research, Frederick, Maryland, USA
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Friedman SR, Downing MJ, Smyrnov P, Nikolopoulos G, Schneider JA, Livak B, Magiorkinis G, Slobodianyk L, Vasylyeva TI, Paraskevis D, Psichogiou M, Sypsa V, Malliori MM, Hatzakis A. Socially-integrated transdisciplinary HIV prevention. AIDS Behav 2014; 18:1821-34. [PMID: 24165983 DOI: 10.1007/s10461-013-0643-5] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Current ideas about HIV prevention include a mixture of primarily biomedical interventions, socio-mechanical interventions such as sterile syringe and condom distribution, and behavioral interventions. This article presents a framework for socially-integrated transdisciplinary HIV prevention that may improve current prevention efforts. It first describes one socially-integrated transdisciplinary intervention project, the Transmission Reduction Intervention Project. We focus on how social aspects of the intervention integrate its component parts across disciplines and processes at different levels of analysis. We then present socially-integrated perspectives about how to improve combination antiretroviral treatment (cART) processes at the population level in order to solve the problems of the treatment cascade and make "treatment as prevention" more effective. Finally, we discuss some remaining problems and issues in such a social transdisciplinary intervention in the hope that other researchers and public health agents will develop additional socially-integrated interventions for HIV and other diseases.
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Affiliation(s)
- Samuel R Friedman
- Institute of Infectious Diseases Research, National Development and Research Institutes, Inc., 71 West 23rd Street, 8th Floor, New York, NY, 10010, USA,
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Abstract
PURPOSE OF REVIEW With progressive age, the immune system and the propensity for abnormal immunity change fundamentally. Individuals greater than 50 years of age are not only more susceptible to infection and cancer, but also at higher risk for chronic inflammation and immune-mediated tissue damage. The process of immunosenescence is accelerated in rheumatoid arthritis (RA). RECENT FINDINGS Premature T-cell senescence occurs not only in RA, but also has been involved in morbidity and mortality of chronic HIV infection. Senescent cells acquire the 'senescence-associated secretory phenotype', which promotes and sustains tissue inflammation. Molecular mechanisms underlying T-cell aging are beginning to be understood. In addition to the contraction of T-cell diversity because of uneven clonal expansion, senescent T cells have defects in balancing cytoplasmic kinase and phosphatase activities, changing their activation thresholds. Also, leakiness in repairing DNA lesions and uncapped telomeres imposes genomic stress. Age-induced changes in the tissue microenvironment may alter the T-cell responses. SUMMARY Gain-of-function and loss-of-function in senescent T cells undermine protective immunity and create the conditions for chronic tissue inflammation, a combination typically encountered in RA. Genetic programs involved in T-cell signaling and DNA repair are of high interest in the search for underlying molecular defects.
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Gwadz M, Applegate E, Cleland C, Leonard NR, Wolfe H, Salomon N, Belkin M, Riedel M, Banfield A, Sanfilippo L, Wagner A, Mildvan D. HIV-Infected Individuals Who Delay, Decline, or Discontinue Antiretroviral Therapy: Comparing Clinic- and Peer-Recruited Cohorts. Front Public Health 2014; 2:81. [PMID: 25077137 PMCID: PMC4100062 DOI: 10.3389/fpubh.2014.00081] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2014] [Accepted: 06/29/2014] [Indexed: 01/05/2023] Open
Abstract
A substantial proportion of persons living with HIV/AIDS (PLHA) delay, decline, or discontinue antiretroviral therapy (ART) when it is medically indicated (40–45%), largely African-Americans and Latinos/Hispanics. This study explores the feasibility of locating PLHA, who are not on ART (PLHA-NOA) through clinics and peer-referral; compares the two cohorts on multi-level barriers to ART; and examines readiness to initiate/reinitiate ART, a predictor of treatment outcomes. We recruited adult HIV-infected African-American and Latino/Hispanic PLHA-NOA through HIV hospital clinics and peer-referral in 2012–2013. Participants were engaged in structured 1-h assessments with reliable/valid measures on barriers to ART. We found that recruitment through peers (63.2%, 60/95) was more feasible than in clinics (36.8%, 35/90). Participants were 48.0 years old and had lived with HIV for 14.7 years on average, and 56.8% had taken ART previously. Most (61.1%) were male and African-American (76.8%), and 23.2% were Latino/Hispanic. Peer-recruited participants were older, had lived with HIV longer, were less engaged in HIV care, and were more likely to have taken ART previously. The cohorts differed in reasons for discontinuing ART. Levels of ART knowledge were comparable between cohorts (68.5% correct), and there were no differences in attitudes toward ART (e.g., mistrust), which were in the neutral range. In bivariate linear regression, readiness for ART was negatively associated with physician mistrust (B = −10.4) and positively associated with self-efficacy (B = 5.5), positive outcome expectancies (B = 6.3), beliefs about personal necessity of ART (B = 17.5), and positive internal norms (B = 7.9). This study demonstrates the feasibility of engaging this vulnerable population through peer-referral. Peer-recruited PLHA evidence particularly high rates of risk factors compared to those in hospital clinics. Interventions to support ART initiation and continuation are sorely needed for both subgroups.
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Affiliation(s)
- Marya Gwadz
- Center for Drug Use and HIV Research (CDUHR), New York University, College of Nursing , New York, NY , USA
| | - Elizabeth Applegate
- Center for Drug Use and HIV Research (CDUHR), New York University, College of Nursing , New York, NY , USA
| | - Charles Cleland
- Center for Drug Use and HIV Research (CDUHR), New York University, College of Nursing , New York, NY , USA
| | - Noelle Regina Leonard
- Center for Drug Use and HIV Research (CDUHR), New York University, College of Nursing , New York, NY , USA
| | - Hannah Wolfe
- Spencer Cox Center for Health, Mount Sinai St. Luke's-Roosevelt Hospital Center , New York, NY , USA
| | - Nadim Salomon
- Peter Kruger Clinic, Mount Sinai Beth Israel Medical Center , New York, NY , USA
| | - Mindy Belkin
- Center for Drug Use and HIV Research (CDUHR), New York University, College of Nursing , New York, NY , USA
| | - Marion Riedel
- School of Social Work, Columbia University , New York, NY , USA
| | - Angela Banfield
- Center for Drug Use and HIV Research (CDUHR), New York University, College of Nursing , New York, NY , USA
| | - Lisa Sanfilippo
- Center for Drug Use and HIV Research (CDUHR), New York University, College of Nursing , New York, NY , USA
| | - Andrea Wagner
- Center for Drug Use and HIV Research (CDUHR), New York University, College of Nursing , New York, NY , USA
| | - Donna Mildvan
- Department of Infectious Diseases, Mount Sinai Beth Israel Medical Center , New York, NY , USA
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Goetz MB, Hoang T, Kan VL, Rimland D, Rodriguez-Barradas M. Development and validation of an algorithm to identify patients newly diagnosed with HIV infection from electronic health records. AIDS Res Hum Retroviruses 2014; 30:626-33. [PMID: 24564256 DOI: 10.1089/aid.2013.0287] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
An algorithm was developed that identifies patients with new diagnoses of HIV infection by the use of electronic health records. It was based on the sequence of HIV diagnostic tests, entry of ICD-9-CM diagnostic codes, and measurement of HIV-1 plasma RNA levels in persons undergoing HIV testing from 2006 to 2012 at four large urban Veterans Health Administration (VHA) facilities. Source data were obtained from the VHA National Corporate Data Warehouse. Chart review was done by a single trained abstractor to validate site-level data regarding new diagnoses. We identified 1,153 patients as having a positive HIV diagnostic test within the VHA. Of these, 57% were determined to have prior knowledge of their HIV status from testing at non-VHA facilities. An algorithm based on the sequence and results of available laboratory tests and ICD-9-CM entries identified new HIV diagnoses with a sensitivity of 83%, specificity of 86%, positive predictive value of 85%, and negative predictive value of 90%. There were no meaningful demographic or clinical differences between newly diagnosed patients who were correctly or incorrectly classified by the algorithm. We have validated a method to identify cases of new diagnosis of HIV infection in large administrative datasets. This method, which has a sensitivity of 83%, specificity of 86%, positive predictive value of 85%, and negative predictive value of 90% can be used in analyses of the epidemiology of newly diagnosed HIV infection.
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Affiliation(s)
- Matthew Bidwell Goetz
- VA Greater Los Angeles Healthcare System and David Geffen School of Medicine, University of California, Los Angeles, California
| | - Tuyen Hoang
- VA Greater Los Angeles Healthcare System and David Geffen School of Medicine, University of California, Los Angeles, California
| | - Virginia L. Kan
- Washington DC VA Medical Center and George Washington University School of Medicine, Washington, District of Columbia
| | - David Rimland
- Atlanta VA Medical Center and Emory University School of Medicine, Atlanta, Georgia
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Geopolitical and cultural factors affecting ARV adherence on the US-Mexico border. J Immigr Minor Health 2014; 15:969-74. [PMID: 22797951 DOI: 10.1007/s10903-012-9681-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
The data discussed represent the findings from a study by the NIH-funded Hispanic Health Disparities Research Center, exploring the influence of institutional and psychosocial factors on adherence to antiretroviral medications by Mexican-origin persons living with AIDS on the US-Mexico Border. A qualitative approach was utilized consisting of clinic observations, baseline and follow-up interviews with patients (N = 113), key informant interviews (N = 9) and focus groups (5) with patients and health providers. Findings include the social-normative, institutional and geo-political factors affecting treatment and service delivery as well as individual variation and culturally patterned behaviors. ARV adherence and retention were found to depend on complex interactions and negotiation of co-occurring factors including the experience of medications and side-effects, patient/provider relationships, cultural norms and the changing dynamics of international borders. We note effects of drug-related violence which created border-crossing obstacles influencing mobility, access to services and adherence.
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Abstract
With the advent of effective combination antiretroviral therapy, HIV infection has been transformed from a fatal disease to a chronic condition. There is renewed clinical interest in long-term morbidities, including malignancies that occur disproportionately within this population. Non-AIDS-defining cancers (NADCs) are a significant source of morbidity and mortality in the aging HIV-infected population. There are data to suggest that incidence rates are elevated among HIV-infected individuals for many cancer sites, particularly those with a confirmed or suspected infectious etiology. The complex interplay between behavioral risk factors, coexistence of viral infections, immunodeficiency and antiretroviral therapy makes it difficult to analyze why certain cancers develop more frequently in HIV-infected individuals. The challenge to clinicians caring for HIV-infected patients is to develop and implement effective means to screen, treat, and prevent NADCs in the future. This review presents data on whether NADCs are increased in the HIV-Infected population, as well as ongoing research on epidemiology, prevention and pathogenesis of this evolving aspect of the HIV epidemic.
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78
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Hughes AJ, Mattson CL, Scheer S, Beer L, Skarbinski J. Discontinuation of antiretroviral therapy among adults receiving HIV care in the United States. J Acquir Immune Defic Syndr 2014; 66:80-9. [PMID: 24326608 PMCID: PMC5091800 DOI: 10.1097/qai.0000000000000084] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Continuous antiretroviral therapy (ART) is important for maintaining viral suppression. This analysis estimates prevalence of and reason for ART discontinuation. METHODS Three-stage sampling was used to obtain a nationally representative, cross-sectional sample of HIV-infected adults receiving HIV care. Face-to-face interviews and medical record abstractions were collected from June 2009 to May 2010. Data were weighted based on known probabilities of selection and adjusted for nonresponse. Patient characteristics of ART discontinuation, defined as not currently taking ART, stratified by provider-initiated versus non-provider-initiated discontinuation, were examined. Weighted logistic regression models predicted factors associated with ART discontinuation. RESULTS Of adults receiving HIV care in the United States who reported ever initiating ART, 5.6% discontinued treatment. Half of those who discontinued treatment reported provider-initiated discontinuation. Provider-initiated ART discontinuation patients were more likely to have a nadir CD4 ≥ 200 cells per cubic millimeter. Non-provider-initiated ART discontinuation patients were more likely to have unmet need for supportive services and to have not received HIV care in the past 3 months. Among all patients who discontinued, younger age, female gender, not having continuous health insurance, incarceration, injection drug use, nadir CD4 count ≥ 2 00 cells per cubic millimeter, unmet need for supportive services, no care in the past 3 months and HIV diagnosis ≥ 5 years before interview were independently associated with ART discontinuation. CONCLUSIONS These findings inform development of interventions to increase ART persistence by identifying groups at increased risk of ART discontinuation. Evidence-based interventions targeting vulnerable populations are needed and are increasingly important as recent HIV treatment guidelines have recommended universal ART.
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Affiliation(s)
| | - Christine L. Mattson
- Division of HIV/AIDS Prevention, Center for Disease Control and Prevention, Atlanta, GA
| | - Susan Scheer
- San Francisco Department of Public Health, San Francisco, CA
| | - Linda Beer
- Division of HIV/AIDS Prevention, Center for Disease Control and Prevention, Atlanta, GA
| | - Jacek Skarbinski
- Division of HIV/AIDS Prevention, Center for Disease Control and Prevention, Atlanta, GA
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Tedaldi EM, Richardson JT, Debes R, Young B, Chmiel JS, Durham MD, Brooks JT, Buchacz K. Retention in care within 1 year of initial HIV care visit in a multisite US cohort: who's in and who's out? J Int Assoc Provid AIDS Care 2014; 13:232-41. [PMID: 24493009 DOI: 10.1177/2325957413514631] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Biannual attendance at medical visits is an established measure of retention in HIV care. We examined factors associated with attending at least 2 clinic visits at least 90 days apart among HIV-infected, antiretroviral therapy (ART)-naive HIV Outpatient Study participants entering care during 2000 to 2011. Of 1441 patients, 85% were retained in care during the first year of observation. Starting ART during the year was the strongest correlate of retention (adjusted odds ratio [aOR] 6.4, 95% confidence interval [CI] 4.4-9.4). After adjusting for starting ART, publicly insured patients (aOR 0.6, 95% CI 0.4-1.0), and patients with baseline CD4 counts <200 cells/mm(3) (aOR 0.5, 95% CI 0.3-0.9) or missing CD4 counts (aOR 0.3, 95% CI 0.2-0.6) were less likely to be retained in care. Although most patients had recommended biannual care visits, some ART-naive individuals may require additional interventions to remain in care. Promptly initiating ART may facilitate engagement in care.
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Affiliation(s)
- Ellen M Tedaldi
- Department of Medicine, Temple University School of Medicine, Philadelphia, PA, USA
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80
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Johnson EN, Roediger MP, Landrum ML, Crum-Cianflone NF, Weintrob AC, Ganesan A, Okulicz JF, Macalino GE, Agan BK. Race/ethnicity and HAART initiation in a military HIV infected cohort. AIDS Res Ther 2014; 11:10. [PMID: 24460764 PMCID: PMC3922739 DOI: 10.1186/1742-6405-11-10] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2013] [Accepted: 01/15/2014] [Indexed: 11/24/2022] Open
Abstract
Background Prior studies have suggested that HAART initiation may vary by race/ethnicity. Utilizing the U.S. military healthcare system, which minimizes confounding from healthcare access, we analyzed whether timing of HAART initiation and the appropriate initiation of primary prophylaxis among those at high risk for pneumocystis pneumonia (PCP) varies by race/ethnicity. Methods Participants in the U.S. Military HIV Natural History Study from 1998-2009 who had not initiated HAART before 1998 and who, based on DHHS guidelines, had a definite indication for HAART (CD4 <200, AIDS event or severe symptoms; Group A), an indication to consider HAART (including CD4 <350; Group B) or electively started HAART (CD4 >350; Group C) were analyzed for factors associated with HAART initiation. In a secondary analysis, participants were also evaluated for factors associated with starting primary PCP prophylaxis within four months of a CD4 count <200 cells/mm3. Multiple logistic regression was used to compare those who started vs. delayed therapy; comparisons were expressed as odds ratios (OR). Results 1262 participants were evaluated in the analysis of HAART initiation (A = 208, B = 637, C = 479 [62 participants were evaluated in both Groups A and B]; 94% male, 46% African American, 40% Caucasian). Race/ethnicity was not associated with HAART initiation in Groups A or B. In Group C, African American race/ethnicity was associated with lower odds of initiating HAART (OR 0.49, p = 0.04). Race and ethnicity were also not associated with the initiation of primary PCP prophylaxis among the 408 participants who were at risk. Conclusions No disparities in the initiation of HAART or primary PCP prophylaxis according to race/ethnicity were seen among those with an indication for therapy. Among those electively initiating HAART at the highest CD4 cell counts, African American race/ethnicity was associated with decreased odds of starting. This suggests that free healthcare can potentially overcome some of the observed disparities in HIV care, but that unmeasured factors may contribute to differences in elective care decisions.
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81
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Drechsler H, Zhang S, Holodniy M, Bedimo R. CD4 counts and mortality in virologically suppressed US veterans. J Int Assoc Provid AIDS Care 2014; 13:120-6. [PMID: 24378517 DOI: 10.1177/2325957413512153] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
We used the Veterans Health Administration (VA) HIV Clinical Case Registry (CCR) to evaluate the association between annual CD4 averages and all-cause mortality in HIV-infected veterans during their initial episode of suppressive highly active antiretroviral therapy (HAART). We observed 1083 deaths in 14 769 patients. Unadjusted mortality rates in the top and bottom CD4 quintiles differed significantly from the mid CD4 strata. Mortality in the top CD4 quintile (≥720 cells/mm(3)) was 14.1/1000 patient-years, 95% confidence interval (CI): 10.1-18.2, compared with 20.4 (CI: 15.5-25.3) in the next lower CD4 stratum (530-719 cells/mm(3)). This difference was significant in Cox proportional hazards model, controlling for demographics, hepatitis co-infections, low-level viremia, HAART adherence, and refill rates of individual antiretrovirals (HR: 1.4, CI: 1.13-1.73). Our results support early HAART initiation as advocated by the current US treatment guidelines for HIV infection.
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82
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Samji H, Cescon A, Hogg RS, Modur SP, Althoff KN, Buchacz K, Burchell AN, Cohen M, Gebo KA, Gill MJ, Justice A, Kirk G, Klein MB, Korthuis PT, Martin J, Napravnik S, Rourke SB, Sterling TR, Silverberg MJ, Deeks S, Jacobson LP, Bosch RJ, Kitahata MM, Goedert JJ, Moore R, Gange SJ. Closing the gap: increases in life expectancy among treated HIV-positive individuals in the United States and Canada. PLoS One 2013; 8:e81355. [PMID: 24367482 PMCID: PMC3867319 DOI: 10.1371/journal.pone.0081355] [Citation(s) in RCA: 1033] [Impact Index Per Article: 93.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2013] [Accepted: 10/11/2013] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Combination antiretroviral therapy (ART) has significantly increased survival among HIV-positive adults in the United States (U.S.) and Canada, but gains in life expectancy for this region have not been well characterized. We aim to estimate temporal changes in life expectancy among HIV-positive adults on ART from 2000-2007 in the U.S. and Canada. METHODS Participants were from the North American AIDS Cohort Collaboration on Research and Design (NA-ACCORD), aged ≥20 years and on ART. Mortality rates were calculated using participants' person-time from January 1, 2000 or ART initiation until death, loss to follow-up, or administrative censoring December 31, 2007. Life expectancy at age 20, defined as the average number of additional years that a person of a specific age will live, provided the current age-specific mortality rates remain constant, was estimated using abridged life tables. RESULTS The crude mortality rate was 19.8/1,000 person-years, among 22,937 individuals contributing 82,022 person-years and 1,622 deaths. Life expectancy increased from 36.1 [standard error (SE) 0.5] to 51.4 [SE 0.5] years from 2000-2002 to 2006-2007. Men and women had comparable life expectancies in all periods except the last (2006-2007). Life expectancy was lower for individuals with a history of injection drug use, non-whites, and in patients with baseline CD4 counts <350 cells/mm(3). CONCLUSIONS A 20-year-old HIV-positive adult on ART in the U.S. or Canada is expected to live into their early 70 s, a life expectancy approaching that of the general population. Differences by sex, race, HIV transmission risk group, and CD4 count remain.
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Affiliation(s)
- Hasina Samji
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada
| | - Angela Cescon
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada
| | - Robert S. Hogg
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada
- Simon Fraser University, Burnaby, British Columbia, Canada
| | - Sharada P. Modur
- Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Keri N. Althoff
- Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Kate Buchacz
- Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | | | - Mardge Cohen
- The Core Center, Bureau of Health Services of Cook County, Chicago, Illinois, United States of America
| | - Kelly A. Gebo
- Johns Hopkins University, Baltimore, Maryland, United States of America
| | | | - Amy Justice
- Veterans Administration Connecticut Healthcare System and Yale University, West Haven, Connecticut, United States of America
| | - Gregory Kirk
- Johns Hopkins University, Baltimore, Maryland, United States of America
| | | | - P. Todd Korthuis
- Oregon Health and Science University, Portland, Oregon, United States of America
| | - Jeff Martin
- University of California San Francisco, San Francisco, California, United States of America
| | - Sonia Napravnik
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | | | | | - Michael J. Silverberg
- Kaiser Permanente Northern California, Oakland, California, United States of America
| | - Stephen Deeks
- San Francisco General Hospital, University of California San Francisco, San Francisco, California, United States of America
| | - Lisa P. Jacobson
- Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Ronald J. Bosch
- Harvard School of Public Health, Boston, Massachusetts, United States of America
| | - Mari M. Kitahata
- University of Washington, Seattle, Washington, United States of America
| | - James J. Goedert
- National Cancer Institute, Rockville, Maryland, United States of America
| | - Richard Moore
- Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Stephen J. Gange
- Johns Hopkins University, Baltimore, Maryland, United States of America
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Lahuerta M, Ue F, Hoffman S, Elul B, Kulkarni SG, Wu Y, Nuwagaba-Biribonwoha H, Remien RH, El Sadr W, Nash D. The problem of late ART initiation in Sub-Saharan Africa: a transient aspect of scale-up or a long-term phenomenon? J Health Care Poor Underserved 2013; 24:359-83. [PMID: 23377739 DOI: 10.1353/hpu.2013.0014] [Citation(s) in RCA: 85] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Efforts to scale-up HIV care and treatment have been successful at initiating large numbers of patients onto antiretroviral therapy (ART), although persistent challenges remain to optimizing scale-up effectiveness in both resource-rich and resource-limited settings. Among the most important are very high rates of ART initiation in the advanced stages of HIV disease, which in turn drive morbidity, mortality, and onward transmission of HIV. With a focus on sub-Saharan Africa, this review article presents a conceptual framework for a broader discussion of the persistent problem of late ART initiation, including a need for more focus on the upstream precursors (late HIV diagnosis and late enrollment into HIV care) and their determinants. Without additional research and identification of multilevel interventions that successfully promote earlier initiation of ART, the problem of late ART initiation will persist, significantly undermining the long-term impact of HIV care scale-up on reducing mortality and controlling the HIV epidemic.
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Affiliation(s)
- Maria Lahuerta
- ICAP-Columbia University, Mailman School of Public Health, New York, NY 10032, USA.
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84
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Palmer AK, Cescon A, Chan K, Cooper C, Raboud JM, Miller CL, Burchell AN, Klein MB, Machouf N, Montaner JSG, Tsoukas C, Hogg RS, Loutfy MR. Factors Associated with Late Initiation of Highly Active Antiretroviral Therapy among Young HIV-Positive Men and Women Aged 18 to 29 Years in Canada. ACTA ACUST UNITED AC 2013; 13:56-62. [DOI: 10.1177/2325957413510606] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Initiating highly active antiretroviral therapy (HAART) with low CD4 counts or AIDS-defining illnesses (ADIs) increases risk of treatment failure and death. We examined factors associated with late initiation among 18- to 29-year-olds within the Canadian Observational Cohort (CANOC) collaboration, a multi-site study of HIV-positive persons who initiated HAART after 2000. Late initiation was defined as beginning HAART with a CD4 count <200 cells/mm3 and/or having a baseline ADI. Multivariable logistic regression was used to identify independent correlates of late initiation. In total, 1026 individuals (422 from British Columbia, 400 from Ontario, and 204 from Quebec) met our age criteria. At HAART initiation, median age was 27 years (interquartile range, 24, 28 years). A total of 412 individuals (40%) identified as late initiators. Late initiation was associated with female gender, age >25 years at initiation, initiating treatment in earlier years, and having higher baseline viral load. The high number of young adults in our cohort starting HAART late indicates important target populations for specialized services, increased testing, and linkages to care.
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Affiliation(s)
- Alexis K. Palmer
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada
- Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada
| | - Angela Cescon
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada
| | - Keith Chan
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada
| | - Curtis Cooper
- The Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - Janet M. Raboud
- University of Toronto, Toronto, ON, Canada
- Division of Infectious Diseases, University Health Network, Toronto, ON, Canada
| | - Caroline L. Miller
- Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada
| | | | - Marina B. Klein
- Faculty of Medicine, McGill University, Montreal, QC, Canada
- The Montreal Chest Institute, McGill University Health Centre, Montreal, QC, Canada
| | - Nima Machouf
- Clinique Medicale l’Actuel, Montreal, QC, Canada
| | - Julio S. G. Montaner
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada
- Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Chris Tsoukas
- Faculty of Medicine, McGill University, Montreal, QC, Canada
| | - Robert S. Hogg
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada
- Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada
| | - Mona R. Loutfy
- University of Toronto, Toronto, ON, Canada
- Maple Leaf Medical Clinic, Toronto, ON, Canada
- Women’s College Research Institute, Women’s College Hospital, Toronto, ON, Canada
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85
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Sabin CA. Do people with HIV infection have a normal life expectancy in the era of combination antiretroviral therapy? BMC Med 2013; 11:251. [PMID: 24283830 PMCID: PMC4220799 DOI: 10.1186/1741-7015-11-251] [Citation(s) in RCA: 112] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2013] [Accepted: 10/30/2013] [Indexed: 12/18/2022] Open
Abstract
There is evidence that the life expectancy (LE) of individuals infected with the human immunodeficiency virus (HIV) has increased since the introduction of combination antiretroviral therapy (cART). However, mortality rates in recent years in HIV-positive individuals appear to have remained higher than would be expected based on rates seen in the general population. A low CD4 count, whether due to late HIV diagnosis, late initiation of cART, or incomplete adherence to cART, remains the dominant predictor of LE, and thus the individual's disease stage at initiation of cART (or thereafter) certainly contributes to these higher mortality rates. However, individuals with HIV also tend to exhibit lifestyles and behaviors that place them at increased risk of mortality, particularly from non-AIDS causes. Thus, although mortality rates among the HIV population may indeed remain slightly higher than those seen in the general population, they may be no higher than those seen in a more appropriately matched control group. Thus, further improvements in LE may now only be possible if some of the other underlying issues (for example, modification of lifestyle or behavioral factors) are tackled.
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Affiliation(s)
- Caroline A Sabin
- Research Department of Infection and Population Health, UCL, Royal Free Campus, Rowland Hill Street, London NW3 2PF, UK.
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Wohl DA, Kendall MA, Feinberg J, Alston-Smith B, Owens S, Chafey S, Marco M, Maxwell S, Benson C, Keiser P, van der Horst C, Jacobson MA. The clinical impact of continuing to prescribe antiretroviral therapy in patients with advanced AIDS who manifest no virologic or immunologic benefit. PLoS One 2013; 8:e78676. [PMID: 24260125 PMCID: PMC3829816 DOI: 10.1371/journal.pone.0078676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2013] [Accepted: 09/13/2013] [Indexed: 11/19/2022] Open
Abstract
Introduction Despite the efficacy and tolerability of modern antiretroviral therapy (ART), many patients with advanced AIDS prescribed these regimens do not achieve viral suppression or immune reconstitution as a result of poor adherence, drug resistance, or both. The clinical outcomes of continued ART prescription for such patients have not been well characterized. Methods We examined the causes and predictors of all-cause mortality, AIDS-defining conditions, and serious non-AIDS-defining events among a cohort of participants in a clinical trial of pre-emptive therapy for CMV disease. We focused on participants who, despite ART had failed to achieve virologic suppression and substantive immune reconstitution. Results 233 ART-receiving participants entered with a median baseline CD4+ T cell count of 30/mm3 and plasma HIV RNA of 5 log10 copies/mL. During a median 96 weeks of follow-up, 24.0% died (a mortality rate of 10.7/100 patient-years); 27.5% reported a new AIDS-defining condition, and 22.3% a new serious non-AIDS event. Of the deaths, 42.8% were due to an AIDS-defining condition, 44.6% were due to a non-AIDS-defining condition, and 12.5% were of unknown etiology. Decreased risk of mortality was associated with baseline CD4+ T cell count ≥25/mm3 and lower baseline HIV RNA. Conclusions Among patients with advanced AIDS prescribed modern ART who achieve neither virologic suppression nor immune reconstitution, crude mortality percentages appear to be lower than reported in cohorts of patients studied a decade earlier. Also, in contrast to the era before modern ART became available, nearly half of the deaths in our modern-era study were caused by serious non-AIDS-defining events. Even among the most advanced AIDS patients who were not obtaining apparent immunologic and virologic benefit from ART, continued prescription of these medications appears to alter the natural history of AIDS—improving survival and shifting the causes of death from AIDS- to non-AIDS-defining conditions.
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Affiliation(s)
- David A. Wohl
- University of North Carolina, Chapel Hill, North Carolina, United States of America
- * E-mail:
| | - Michelle A. Kendall
- Harvard School of Public Health, Boston, Massachusetts, United States of America
| | - Judith Feinberg
- University of Cincinnati, Cincinnati, Ohio, United States of America
| | - Beverly Alston-Smith
- Division of AIDS, National Institutes of Health, Bethesda, Maryland, United States of America
| | - Susan Owens
- Frontier Science & Technology Foundation, Amherst, New York, United States of America
| | - Suzette Chafey
- University of California Los Angeles, Los Angeles, California, United States of America
| | - Michael Marco
- Columbia University, New York, New York, United States of America
| | - Sharon Maxwell
- University of Washington, Seattle, Washington, United States of America
| | - Constance Benson
- University of California San Diego, San Diego, California, United States of America
| | - Philip Keiser
- University of Texas – Southwestern Medical Center, Dallas, Texas, United States of America
| | | | - Mark A. Jacobson
- University of California San Francisco, San Francisco, California, United States of America
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Zhu H, Napravnik S, Eron JJ, Cole SR, Ma Y, Wohl DA, Dou Z, Zhang Y, Liu Z, Zhao D, Yu L, Liu X, Cohen MS, Zhang F. Decreasing excess mortality of HIV-infected patients initiating antiretroviral therapy: comparison with mortality in general population in China, 2003-2009. J Acquir Immune Defic Syndr 2013; 63:e150-7. [PMID: 23572014 DOI: 10.1097/qai.0b013e3182948d82] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To evaluate excess mortality across calendar time comparing HIV-infected patients receiving combination antiretroviral therapy (cART) with the general Chinese population. METHODS Patients receiving free cART through the National Free Antiretroviral Therapy Program (NFATP) between January 1, 2003, and December 31, 2009, were included. Observed mortality rates, excess mortality rates, and standardized mortality ratios were calculated by calendar periods. Factors associated with excess mortality across calendar time were evaluated in multivariable Poisson regression models. RESULTS Among 64,836 HIV-infected patients, the observed and excess mortality rates in 2003-2004 were 9.5 deaths per 100 person-years [95% confidence interval (CI): 8.8 to 10.2] and 9.1 (95% CI: 8.5 to 9.8); in 2008-2009, these decreased to 5.6 (95% CI: 5.4 to 5.8) and 5.2 (95% CI: 5.0 to 5.4), respectively. The adjusted excess hazard ratio (eHR) for 2003-2004 in comparison to 2008-2009 was 1.27 (95% CI: 1.11 to 1.45). Patients initiating cART at CD4 cell counts <50 cells per microliter in comparison with ≥350 cells per microliter had an adjusted eHR of 9.92 (95% CI: 8.59 to 11.44). Patients starting cART at older ages also had greater excess mortality with an eHR of 1.63 (95% CI: 1.47 to 1.82) comparing ages ≥45 to 18-29 years. Standardized mortality ratio results were consistent with those for excess mortality. CONCLUSIONS Substantial decreases in excess mortality were observed from 2003 to 2009 in China among HIV-infected patients receiving free cART. However, mortality among HIV-infected patients remained higher than the general Chinese population. As more efficacious first- and second-line cART regimens become increasingly available to Chinese HIV-infected patients, further reductions in overall and excess mortality are likely.
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Affiliation(s)
- Hao Zhu
- *Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC; †Division of Treatment and Care, National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China; ‡Division of Infectious Diseases, School of Medicine, University of North Carolina, Chapel Hill, NC; and §Division of Infectious Diseases, Beijing Ditan Hospital Capital Medical University, Beijing, China
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Speybroeck N, Van Malderen C, Harper S, Müller B, Devleesschauwer B. Simulation models for socioeconomic inequalities in health: a systematic review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2013; 10:5750-80. [PMID: 24192788 PMCID: PMC3863870 DOI: 10.3390/ijerph10115750] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/05/2013] [Revised: 10/14/2013] [Accepted: 10/16/2013] [Indexed: 01/15/2023]
Abstract
Background: The emergence and evolution of socioeconomic inequalities in health involves multiple factors interacting with each other at different levels. Simulation models are suitable for studying such complex and dynamic systems and have the ability to test the impact of policy interventions in silico. Objective: To explore how simulation models were used in the field of socioeconomic inequalities in health. Methods: An electronic search of studies assessing socioeconomic inequalities in health using a simulation model was conducted. Characteristics of the simulation models were extracted and distinct simulation approaches were identified. As an illustration, a simple agent-based model of the emergence of socioeconomic differences in alcohol abuse was developed. Results: We found 61 studies published between 1989 and 2013. Ten different simulation approaches were identified. The agent-based model illustration showed that multilevel, reciprocal and indirect effects of social determinants on health can be modeled flexibly. Discussion and Conclusions: Based on the review, we discuss the utility of using simulation models for studying health inequalities, and refer to good modeling practices for developing such models. The review and the simulation model example suggest that the use of simulation models may enhance the understanding and debate about existing and new socioeconomic inequalities of health frameworks.
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Affiliation(s)
- Niko Speybroeck
- Institute of Health and Society (IRSS), Université Catholique de Louvain, Brussels 1200, Belgium; E-Mails: (C.M.); (B.D.)
- Author to whom correspondence should be addressed; E-Mail: ; Tel.: +32-2-764-3375; Fax: +32-2-764-3378
| | - Carine Van Malderen
- Institute of Health and Society (IRSS), Université Catholique de Louvain, Brussels 1200, Belgium; E-Mails: (C.M.); (B.D.)
| | - Sam Harper
- Department of Epidemiology, Biostatistics & Occupational Health, McGill University, Montreal, QC H3A0G4, Canada; E-Mail:
| | - Birgit Müller
- Department Ecological Modelling, Helmholtz Centre for Environmental Research—UFZ, Leipzig 04318, Germany; E-Mail:
| | - Brecht Devleesschauwer
- Institute of Health and Society (IRSS), Université Catholique de Louvain, Brussels 1200, Belgium; E-Mails: (C.M.); (B.D.)
- Department of Virology, Parasitology and Immunology, Faculty of Veterinary Medicine, Ghent University, Ghent 9000, Belgium
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Knowlton A, Weir BW, Hughes BS, Southerland RJH, Schultz CW, Sarpatwari R, Wissow L, Links J, Fields J, McWilliams J, Gaasch W. Patient demographic and health factors associated with frequent use of emergency medical services in a midsized city. Acad Emerg Med 2013; 20:1101-11. [PMID: 24238312 DOI: 10.1111/acem.12253] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2012] [Revised: 05/10/2013] [Accepted: 08/09/2013] [Indexed: 10/26/2022]
Abstract
OBJECTIVES To optimize health care utilization, health outcomes, and costs, research is needed to improve an understanding of frequent users of emergency health services. Frequent use of emergency services is associated with high costs of health care and may be indicative of challenges accessing, or poor outcomes of, health care. Patient demographics and health factors related to frequent use of the emergency medical services (EMS) system of a midsized city were identified. Study findings will aid in the development of targeted interventions to improve population health. METHODS The authors reviewed 9-1-1 call dispatch data and Baltimore City Fire Department (BCFD) EMS records from 2008 through 2010. Frequent use was defined as six or more EMS incidents in the 23-month period. Analyses used census data to compare demographics of EMS users to their population distribution and examined differences in demographics and health problems of frequent EMS users compared to nonfrequent users. RESULTS Frequent EMS users (n = 1,969) had a range of six to 199 EMS incidents (mean = 11.2) during the observation period, and although they accounted for only 1.5% of EMS users, they were involved in 12.0% of incidents. Frequent users, compared to nonfrequent users and to the population, were more likely to be male, African American, and 45 years of age or older. Of frequent users, the modal age group was 45 to 54 years, accounting for 29.7% of frequent users, which represented twice this age group's population distribution. Furthermore, this age group had the greatest overrepresentation of males (63.0% of frequent users) and was the peak age group for incidents related to substance abuse (28.0% of frequent users' incidents in this age group). Frequent users, compared to nonfrequent users, had lower levels of incidents related to trauma (5.1% vs. 16.7%) and higher levels of medical incidents (94.8% vs. 82.9%). As proportions of EMS incidents among frequent versus nonfrequent users, respiratory, mental health, and seizure-related incidents were highest in the youngest age groups; substance abuse-related incidents were highest in those middle-aged (35 to 44 and 45 to 54 years). Of health problems, behavioral health (mental health or substance use) contributed most to frequent EMS use (23.4% of frequent users' incidents). Across all incidents, 65.8% of frequent users had indications of behavioral health problems, representing 6.6-fold higher odds than nonfrequent users (22.5%). Frequent compared to nonfrequent users also had higher levels of select chronic conditions (diabetes, 39.9% vs. 14.6%; asthma, 40.9% vs. 13.4%; and HIV, 9.1% vs. 2.4%), with unadjusted odds almost four to seven times higher. CONCLUSIONS The study findings revealed the major role of chronic somatic and behavioral health problems in frequent EMS use and that rates of frequent use were highest among those middle-aged, African American, and male. These results suggest the need for coordination of EMS with community-based, integrated medical and behavioral health services to improve access and use of preventive services, with implications for health outcomes and costs. This study demonstrates the value of EMS patient data in identifying at-risk populations and informing novel, targeted approaches to public health interventions.
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Affiliation(s)
- Amy Knowlton
- Department of Health; Behavior & Society; Johns Hopkins Bloomberg School of Public Health; Baltimore MD
| | - Brian W. Weir
- Department of Health; Behavior & Society; Johns Hopkins Bloomberg School of Public Health; Baltimore MD
| | - Brenna S. Hughes
- Goucher College; Post-Baccalaureate Premedical Program; Baltimore MD
| | | | - Cody W. Schultz
- Goucher College; Post-Baccalaureate Premedical Program; Baltimore MD
| | - Ravi Sarpatwari
- Goucher College; Post-Baccalaureate Premedical Program; Baltimore MD
| | - Lawrence Wissow
- Department of Health; Behavior & Society; Johns Hopkins Bloomberg School of Public Health; Baltimore MD
- The Departments of Psychiatry and Pediatrics; Johns Hopkins School of Medicine; Baltimore MD
| | - Jonathan Links
- The Department of Environmental Health Sciences; Johns Hopkins Bloomberg School of Public Health; Baltimore MD
- The Department of Emergency Medicine; Johns Hopkins School of Medicine; Baltimore MD
| | - Julie Fields
- Department of Health; Behavior & Society; Johns Hopkins Bloomberg School of Public Health; Baltimore MD
- The Department of Emergency Medicine; Johns Hopkins School of Medicine; Baltimore MD
| | - Junette McWilliams
- Department of Health; Behavior & Society; Johns Hopkins Bloomberg School of Public Health; Baltimore MD
| | - Wade Gaasch
- The Department of Emergency Medicine; University of Maryland School of Medicine; Baltimore MD
- The Baltimore City Fire Department; Baltimore MD
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90
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Toth M, Messer LC, Quinlivan EB. Barriers to HIV care for women of color living in the Southeastern US are associated with physical symptoms, social environment, and self-determination. AIDS Patient Care STDS 2013; 27:613-20. [PMID: 24138485 DOI: 10.1089/apc.2013.0030] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
HIV-infected women of color (WOC) face particular barriers to accessing HIV medical care. To understand the impact of physical symptoms, social support, and self-determination on barriers to care, we interviewed HIV-infected women of color. HIV-infected WOC (N=141), attending an academic infectious disease clinic for HIV care in North Carolina, completed the Barriers to Care scale and were categorized as reporting a history of low (less than four of eleven barriers) or high (five or more) barriers to care. Binomial regression was used to estimate prevalence ratios and risk differences of reported barriers to care and its correlates such as depression, anxiety, illness-severity, psychological abuse, social support, treatment-specific social support, and self-determination (autonomy, relatedness, competency). A lower risk of reporting five or more barriers to care was associated with higher levels of autonomy (PR=0.93, 95% CI: 0.89, 0.96), relatedness (PR=0.92, 95% CI: 0.89, 0.94), competency (PR=0.93, 95% CI: 0.87, 0.98), and social support (PR=0.24, 95% CI: 0.81, 0.81). Depression, illness severity, and psychological abuse were associated with a greater risk of having five or more barriers to care. There are multiple social and psychological factors that contribute to perceived barriers to HIV care among WOC in the southeastern USA. Interventions that promote social support and increase individual self-determination have the potential to improve access to HIV care for WOC.
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Affiliation(s)
- Matthew Toth
- Gillings School of Global Public Health, University of North Carolina-Chapel Hill, North Carolina
- Center for Health Policy and Inequalities Research, Duke University, Durham, North Carolina
| | - Lynne C. Messer
- School of Community Health, College of Urban and Public Affairs, Portland State University, Portland, Oregon
| | - E. Byrd Quinlivan
- Center for Infectious Diseases, University of North Carolina-Chapel Hill, North Carolina
- Division of Infectious Diseases, Department of Medicine, University of North Carolina-Chapel Hill, North Carolina
- Center for AIDS Research, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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91
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Sandkovsky U, Robertson KR, Meza JL, High RR, Bonasera SJ, Fisher CM, Marsh AJ, Sheehy MK, Fox HS, Swindells S. Pilot study of younger and older HIV-infected adults using traditional and novel functional assessments. HIV CLINICAL TRIALS 2013; 14:165-74. [PMID: 23924589 DOI: 10.1310/hct1404-165] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVES Emerging data suggest that HIV disease and its treatment affect the aging process. Accurate and reliable measures of functional status are needed to investigate this further. DESIGN A pilot study in groups of younger and older HIV-infected adults using objective measures of function. METHODS Evaluations included neuropsychological testing, grip strength, balance assessed by the Wii Balance Board, and actigraphy. Surveys were used for depression, fatigue, loneliness, self-reported activity level, and sexual function. Two-samplet test or Wilcoxon rank sum tests were used for continuous variables and exact chi-square tests were used for comparison between groups. RESULTS Twenty-one participants were 20 to 40 years old (younger; mean age, 31.5), and 20 were more than 50 years old (older; mean age, 56.5). There was no difference between groups for depression, fatigue, or loneliness. Overall, there was a trend to lower scores in the older age group for neuropsychologicalz score (P = .11) and for verbal learning (P = .09). Functioning in the memory domain was significantly lower in older subjects (P = .007). There was no difference in executive function, speed of processing, memory, motor skills, or total activity. Gender differences in sexual function were observed. Four older and 3 younger participants met the definition of frailty. Total activity by actigraphy did not correlate well with self-reported activity. CONCLUSIONS Objective tests were well accepted and feasible to perform, although not all are suitable for widespread clinical or research use. Objective measurements of activity did not correlate well with patient self-report, which has implications for future studies in this area.
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Affiliation(s)
- Uriel Sandkovsky
- Department of Internal Medicine and Division of Infectious Diseases, University of Nebraska Medical Center, Omaha, NE, USA.
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92
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Sweeney P, Gardner LI, Buchacz K, Garland PM, Mugavero MJ, Bosshart JT, Shouse RL, Bertolli J. Shifting the paradigm: using HIV surveillance data as a foundation for improving HIV care and preventing HIV infection. Milbank Q 2013; 91:558-603. [PMID: 24028699 DOI: 10.1111/milq.12018] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
CONTEXT Reducing HIV incidence in the United States and improving health outcomes for people living with HIV hinge on improving access to highly effective treatment and overcoming barriers to continuous treatment. Using laboratory tests routinely reported for HIV surveillance to monitor individuals' receipt of HIV care and contacting them to facilitate optimal care could help achieve these objectives. Historically, surveillance-based public health intervention with individuals for HIV control has been controversial because of concerns that risks to privacy and autonomy could outweigh benefits. But with the availability of lifesaving, transmission-interrupting treatment for HIV infection, some health departments have begun surveillance-based outreach to facilitate HIV medical care. METHODS Guided by ethics frameworks, we explored the ethical arguments for changing the uses of HIV surveillance data. To identify ethical, procedural, and strategic considerations, we reviewed the activities of health departments that are using HIV surveillance data to contact persons identified as needing assistance with initiating or returning to care. FINDINGS Although privacy concerns surrounding the uses of HIV surveillance data still exist, there are ethical concerns associated with not using HIV surveillance to maximize the benefits from HIV medical care and treatment. Early efforts to use surveillance data to facilitate optimal HIV medical care illustrate how the ethical burdens may vary depending on the local context and the specifics of implementation. Health departments laid the foundation for these activities by engaging stakeholders to gain their trust in sharing sensitive information; establishing or strengthening legal, policy and governance infrastructure; and developing communication and follow-up protocols that protect privacy. CONCLUSIONS We describe a shift toward using HIV surveillance to facilitate optimal HIV care. Health departments should review the considerations outlined before implementing new uses of HIV surveillance data, and they should commit to an ongoing review of activities with the objective of balancing beneficence, respect for persons, and justice.
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Affiliation(s)
- Patricia Sweeney
- Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention
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93
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Tao CM, Cho Y, Ng KP, Han X, Oh EJ, Zainah S, Rozainanee MZ, Wang LL. Validation of the Elecsys® HIV combi PT assay for screening and reliable early detection of HIV-1 infection in Asia. J Clin Virol 2013; 58:221-6. [PMID: 23809476 DOI: 10.1016/j.jcv.2013.05.012] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2012] [Revised: 05/15/2013] [Accepted: 05/17/2013] [Indexed: 02/05/2023]
Abstract
BACKGROUND The Elecsys® HIV combi PT assay was developed to allow earlier detection of HIV infection with increased sensitivity and specificity. OBJECTIVES To validate the assay for screening and reliable early detection of HIV-1 infection in Asia. STUDY DESIGN Samples tested reflected those routinely screened in Asia and comprised: HIV-1 antigen lysate (25 samples) and antibody (20 samples) dilutions; seven HIV-1 seroconversion panels (46 samples); 39 patient samples from early infection; 183 known-positive sera; HIV-1 p24 antigen sensitivity panel (seven samples); >500 routine clinical samples per center. The Elecsys® HIV combi PT assay was compared with fourth- (ADVIA Centaur® HIV combo, ARCHITECT® HIV combo, Elecsys® HIV combi) and third-generation (VIRONOSTIKA® HIV Uni-Form II Plus O, Zhuhai Livzon Anti-HIV EIA, Serodia® Particle Agglutination) assays commonly used in the region. RESULTS Overall, the Elecsys® HIV combi PT showed superior or similar sensitivity to the comparators for detecting all subtypes. The assay correctly identified all positive samples, including those taken soon after infection, and detected seroconversion at a similar or shorter time interval than the comparators. The analytical sensitivity of Elecsys® HIV combi PT for HIV-1 p24 antigen was 0.90 IU/mL, which was lower than reported previously. The assay showed good specificity (99.86%) that was superior or equivalent to the other fourth-generation assays tested. CONCLUSIONS These robust data demonstrate the good subtype inclusivity of the Elecsys® HIV combi PT assay and its suitability for screening and reliable early detection of HIV infection in Asia.
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Affiliation(s)
- Chuan Min Tao
- West China Hospital, Sichuan University, 37 GuoXue Xiang, Chengdu, Sichuan Province 610041, China.
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94
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Life expectancy living with HIV: recent estimates and future implications. Curr Opin Infect Dis 2013; 26:17-25. [PMID: 23221765 DOI: 10.1097/qco.0b013e32835ba6b1] [Citation(s) in RCA: 267] [Impact Index Per Article: 24.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
PURPOSE OF REVIEW The life expectancy of people living with HIV has dramatically increased since effective antiretroviral therapy has been available, and still continues to improve. Here, we review the latest literature on estimates of life expectancy and consider the implications for future research. RECENT FINDINGS With timely diagnosis, access to a variety of current drugs and good lifelong adherence, people with recently acquired infections can expect to have a life expectancy which is nearly the same as that of HIV-negative individuals. Modelling studies suggest that life expectancy could improve further if there were increased uptake of HIV testing, better antiretroviral regimens and treatment strategies, and the adoption of healthier lifestyles by those living with HIV. In particular, earlier diagnosis is one of the most important factors associated with better life expectancy. A consequence of improved survival is the increasing number of people with HIV who are aged over 50 years old, and further research into the impact of ageing on HIV-positive people will therefore become crucial. The development of age-specific HIV treatment and management guidelines is now called for. SUMMARY Analyses on cohort studies and mathematical modelling studies have been used to estimate life expectancy of those with HIV, providing useful insights of importance to individuals and healthcare planning.
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95
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Pellowski JA, Kalichman SC, Matthews KA, Adler N. A pandemic of the poor: social disadvantage and the U.S. HIV epidemic. AMERICAN PSYCHOLOGIST 2013; 68:197-209. [PMID: 23688088 PMCID: PMC3700367 DOI: 10.1037/a0032694] [Citation(s) in RCA: 300] [Impact Index Per Article: 27.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
The U.S. HIV/AIDS epidemic has evolved over the past 30 years and is now concentrated in socially marginalized and disenfranchised communities. The health disparities in this epidemic are striking, with most HIV infections occurring in sexual minorities and communities of color. While widely recognized, the health disparities in HIV and AIDS are not often discussed. In this article, we examine the factors underlying health disparities in the U.S. HIV epidemic. We first discuss the interlocking relationships between biological, social, and behavioral factors that drive HIV/AIDS epidemics. Guided by a well-established conceptual model of health disparities, we then describe the social positions of those most affected by HIV and AIDS, particularly racial and gender groups. Structural and economic conditions-including environmental resources, constraints, access to care, and psychosocial influences-are examined in relation to HIV disease trajectories. Greater attention to contextual factors and comorbidities is needed to reduce the health disparities in HIV/AIDS.
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96
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Earnshaw VA, Bogart LM, Dovidio JF, Williams DR. Stigma and racial/ethnic HIV disparities: moving toward resilience. AMERICAN PSYCHOLOGIST 2013; 68:225-36. [PMID: 23688090 PMCID: PMC3740715 DOI: 10.1037/a0032705] [Citation(s) in RCA: 321] [Impact Index Per Article: 29.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Prior research suggests that stigma plays a role in racial/ethnic health disparities. However, there is limited understanding about the mechanisms by which stigma contributes to HIV-related disparities in risk, incidence and screening, treatment, and survival and what can be done to reduce the impact of stigma on these disparities. We introduce the Stigma and HIV Disparities Model to describe how societal stigma related to race and ethnicity is associated with racial/ethnic HIV disparities via its manifestations at the structural level (e.g., residential segregation) as well as the individual level among perceivers (e.g., discrimination) and targets (e.g., internalized stigma). We then review evidence of these associations. Because racial/ethnic minorities at risk of and living with HIV often possess multiple stigmas (e.g., HIV-positive, substance use), we adopt an intersectionality framework and conceptualize interdependence among co-occurring stigmas. We further propose a resilience agenda and suggest that intervening on modifiable strength-based moderators of the association between societal stigma and disparities can reduce disparities. Strengthening economic and community empowerment and trust at the structural level, creating common ingroup identities and promoting contact with people living with HIV among perceivers at the individual level, and enhancing social support and adaptive coping among targets at the individual level can improve resilience to societal stigma and ultimately reduce racial/ethnic HIV disparities.
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Affiliation(s)
- Valerie A Earnshaw
- Center for Interdisciplinary Research on AIDS, Yale University, New Haven, CT 06510, USA.
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97
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Bogart LM, Landrine H, Galvan FH, Wagner GJ, Klein DJ. Perceived discrimination and physical health among HIV-positive Black and Latino men who have sex with men. AIDS Behav 2013; 17:1431-41. [PMID: 23297084 DOI: 10.1007/s10461-012-0397-5] [Citation(s) in RCA: 111] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
We conducted the first study to examine health correlates of discrimination due to race/ethnicity, HIV-status, and sexual orientation among 348 HIV-positive Black (n = 181) and Latino (n = 167) men who have sex with men. Participants completed audio computer-assisted self-interviews. In multivariate analyses, Black participants who experienced greater racial discrimination were less likely to have a high CD4 cell count [OR = 0.7, 95 % CI = (0.5, 0.9), p = 0.02], and an undetectable viral load [OR = 0.8, 95 % CI = (0.6, 1.0), p = 0.03], and were more likely to visit the emergency department [OR = 1.3, 95 % CI = (1.0, 1.7), p = 0.04]; the combined three types of discrimination predicted greater AIDS symptoms [F (3,176) = 3.8, p < 0.01]. Among Latinos, the combined three types of discrimination predicted greater medication side effect severity [F (3,163) = 4.6, p < 0.01] and AIDS symptoms [F (3,163) = 3.1, p < 0.05]. Findings suggest that the stress of multiple types of discrimination plays a role in health outcomes.
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98
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Schackman BR. The Value of HIV Screening in the United States in the Era of Effective Treatment. Med Decis Making 2013; 33:457-9. [DOI: 10.1177/0272989x13486978] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Bruce R. Schackman
- Department of Public Health, Weill Cornell Medical College, New York, NY
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99
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Ralston JD, Silverberg MJ, Grothaus L, Leyden WA, Ross T, Stewart C, Carzasty S, Horberg M, Catz SL. Use of web-based shared medical records among patients with HIV. THE AMERICAN JOURNAL OF MANAGED CARE 2013; 19:e114-e124. [PMID: 23725449 PMCID: PMC3951974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
OBJECTIVES To compare use of 7 shared electronic medical record (SMR) features by adult HIV patients. STUDY DESIGN Observational cohort study of adult HIV-positive patients in the first 36 months following implementation of the SMR at Group Health and Kaiser Permanente Northern California. METHODS Automated data from the 36 months following SMR implementation were assessed in 2 integrated delivery systems. Cox proportional hazards analysis identified factors associated with any SMR use. RESULTS Most (3888/7398) patients used the SMR at least once. Users were most likely to view medical test results (49%), use secure messaging (43%), or request appointments (31%) or medication refills (30%). Initial use was associated with new prescription for antiretroviral therapy (rate ratio [RR] 1.65, P <.001), recent change to a CD4+ count of fewer than 200 cells per microliter (RR = 1.34, P <.02), new HIV RNA of 75 or more copies per milliliter (RR = 1.63, P <.001), or recent increase in non-HIV comorbidity score (RR = 1.49, P = .0001). Users were less likely to be women (RR = 0.49, P = .0001), injection drug users (RR = 0.59, P = .0001), or from lower-socioeconomic status neighborhoods (RR = 0.68, P = .0001), and were less likely to be black (RR = 0.38, P = .0001), Hispanic (RR = 0.52, P = .0001) or Asian/Pacific Islander (RR = 0.59, P = .001). CONCLUSIONS SMR use was higher among HIV patients who had indicators of recent increases in healthcare needs and lower among several vulnerable populations.
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Affiliation(s)
- James D. Ralston
- Group Health Research Institute, Group Health Cooperative, Seattle, WA
| | | | - Louis Grothaus
- Group Health Research Institute, Group Health Cooperative, Seattle, WA
| | | | - Tyler Ross
- Group Health Research Institute, Group Health Cooperative, Seattle, WA
| | - Christine Stewart
- Group Health Research Institute, Group Health Cooperative, Seattle, WA
| | - Steven Carzasty
- Group Health Research Institute, Group Health Cooperative, Seattle, WA
| | - Michael Horberg
- Department of Research, Mid-Atlantic Permanente Medical Group, Rockville, MD
| | - Sheryl L. Catz
- Group Health Research Institute, Group Health Cooperative, Seattle, WA
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100
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Schackman BR, Metsch LR, Colfax GN, Leff JA, Wong A, Scott CA, Feaster DJ, Gooden L, Matheson T, Haynes LF, Paltiel AD, Walensky RP. The cost-effectiveness of rapid HIV testing in substance abuse treatment: results of a randomized trial. Drug Alcohol Depend 2013; 128:90-7. [PMID: 22971593 PMCID: PMC3546145 DOI: 10.1016/j.drugalcdep.2012.08.009] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2012] [Revised: 08/01/2012] [Accepted: 08/07/2012] [Indexed: 10/27/2022]
Abstract
BACKGROUND The President's National HIV/AIDS Strategy calls for coupling HIV screening and prevention services with substance abuse treatment programs. Fewer than half of US community-based substance abuse treatment programs make HIV testing available on-site or through referral. METHODS We measured the cost-effectiveness of three HIV testing strategies evaluated in a randomized trial conducted in 12 community-based substance abuse treatment programs in 2009: off-site testing referral, on-site rapid testing with information only, on-site rapid testing with risk-reduction counseling. Data from the trial included patient demographics, prior testing history, test acceptance and receipt of results, undiagnosed HIV prevalence (0.4%) and program costs. The Cost-Effectiveness of Preventing AIDS Complications (CEPAC) computer simulation model was used to project life expectancy, lifetime costs, and quality-adjusted life years (QALYs) for HIV-infected individuals. Incremental cost-effectiveness ratios (2009 US $/QALY) were calculated after adding costs of testing HIV-uninfected individuals; costs and QALYs were discounted at 3% annually. RESULTS Referral for off-site testing is less efficient (dominated) compared to offering on-site testing with information only. The cost-effectiveness ratio for on-site testing with information is $60,300/QALY in the base case, or $76,300/QALY with 0.1% undiagnosed HIV prevalence. HIV risk-reduction counseling costs $36 per person more without additional benefit. CONCLUSIONS A strategy of on-site rapid HIV testing offer with information only in substance abuse treatment programs increases life expectancy at a cost-effectiveness ratio <$100,000/QALY. Policymakers and substance abuse treatment leaders should seek funding to implement on-site rapid HIV testing in substance abuse treatment programs for those not recently tested.
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