Impact of combination therapy for HIV infection on inpatient census

Lipophilic Nucleoside Triphosphate Prodrugs of Anti-HIV Active Nucleoside Analogs as Potential Antiviral Compounds

Nucleoside analogs require three phosphorylation steps catalyzed by cellular kinases to give their triphosphorylated metabolites. Herein, the synthesis of two types of triphosphate prodrugs of different nucleoside analogs is disclosed. Triphosphates comprising: i) a γ-phosphate or γ-phosphonate bearing a bioreversible acyloxybenzyl group and a long alkyl group and ii) γ-dialkyl phosphate/phosphonate modified nucleoside triphosphate analogs. Almost selective conversion of the former TriPPPro-compounds into the corresponding γ-alkylated nucleoside triphosphate derivatives is demonstrated in CEM/0 cell extracts that proved to be stable toward further hydrolysis. The latter γ-dialkylated triphosphate derivatives lead to the slow formation of the corresponding NDPs. Both types of TriPPPro-compounds are highly potent in wild-type CEM/0 cells and more importantly, they exhibit even better activities against HIV-2 replication in CEM/TK- cell cultures. A finding of major importance is that, in primer extension assays, γ-phosphate-modified-NTPs, γ-mono-alkylated-triphosphates, and NDPs prove to be substrates for HIV-RT but not for cellular DNA-polymerases α,γ.

HIV-associated morbidity and mortality in a setting of high ART coverage: prospective surveillance results from a district hospital in Botswana

INTRODUCTION

Antiretroviral therapy (ART) has significantly improved survival in Africa in recent years. In Botswana, where adult HIV prevalence is 21.9%, AIDS-related mortality is estimated to have declined by 58% between 2005 and 2013 following the initial wide-spread introduction of ART, and ART coverage has steadily increased reaching 84% in 2016. However, there remains little data about the burden of HIV and its impact on mortality in the hospital setting where most deaths occur. We aimed to describe the burden of HIV and related morbidity and mortality among hospitalized medical patients in a district hospital in southern Botswana in the era of widespread ART coverage.

METHODS

We prospectively reviewed medical admissions to Scottish Livingstone Hospital from December 2015 to November 2017 and recorded HIV status, demographics, clinical characteristics and final diagnoses at discharge, death or transfer. We ascertained outcomes and determined factors associated with mortality. Results were compared with similar surveillance data collected at the same facility in 2011 to 2012.

RESULTS

A total of 2316 admissions occurred involving 1969 patients; 42.4% were of HIV-positive patients, 46.9% of HIV-negative patients and 10.7% of patients with unknown HIV status. Compared to HIV-negative patients, HIV-positive patients had younger age (mean 42 vs. 64 years, p < 0.0001) and higher mortality (22.2% vs. 18.0%, p = 0.03). Tuberculosis was the leading diagnosis among mortality cases in both groups but accounted for a higher proportion of deaths among HIV-positive admissions (44.5%) compared with HIV-negative admissions (19.4%, p < 0.0001). Compared with similar surveillance in 2011 to 2012, HIV prevalence was lower (42.4% vs. 47.6%, p < 0.01), and among HIV-positive admissions: ART coverage was higher (72.2% vs. 56.2%, p < 0.0001), viral load suppression was similar (78.6% vs. 80.3%, p = 0.77), CD4 counts were higher (55.0% vs. 44.6% with CD4 ≥200 cells/mm3 , p < 0.001), mortality was similar (22.2 vs. 22.7%, p = 0.93), tuberculosis diagnoses increased (27.5% vs. 20.1%, p < 0.01) and tuberculosis-associated mortality was higher (35.9% vs. 24.7%, p = 0.05).

CONCLUSIONS

Despite high ART-coverage in Botswana, HIV-positive patients continue to be disproportionately represented among hospital admissions and deaths. Deaths from tuberculosis may be contributing to lack of reduction in inpatient mortality. Our findings suggest that control of HIV and tuberculosis remain top priorities for reducing inpatient mortality in Botswana.

How has the cost of antiretroviral therapy changed over the years? A database analysis in Italy

Background

The number of human immunodeficiency virus (HIV)-related hospitalizations has decreased worldwide in recent years, due to the availability of combined antiretroviral therapies (cART). The present analysis aimed to analyse the economic, and clinical burden of HIV management, after the introduction of systematic use of cART.

Methods

Data from HIV-infected patients, treated at Policlinico San Martino Hospital in Genova (Italy) were retrospectively collected. A comparison between years 2009 and 2015 was performed. HIV-related admissions were identified by using the Diagnosis-Related Group (DRG) codes. The resource consumption of outpatient services was derived by using a modelling approach. Expenditure for drugs was also analysed, as aggregate data.

Results

The number of HIV-infected patients was 898 in 2009 and 1006 in 2015. Overall, the virological success rate improved from 2009 to 2015, as the percentage of patients with HIV-RNA < 50 copies/mL increased from 79 to 89% (P < 0.05). The average incidence of hospitalizations per-patient decreased from 0.30 in 2009, to 0.13 in 2015. Average expenditure per-patient decreased from €10,107 in 2009 to €9063 in 2015.

Conclusions

The present analysis confirmed the role of cART in controlling HIV viral load and, consequently, in reducing hospitalizations, admissions to day-hospital and the use of outpatient services.

Clinical improvements and economic savings more than compensated the investments required to treat HIV-infected patients with cART. Health Authorities should invest in modern cART supply and universal treatment, to use at best the available resources and obtain a cost-effective improvement of health in people living with HIV. Additional research, with the involvement of different centers and the use of patient-specific data, are recommended to consolidate the findings of this analysis.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-3507-x) contains supplementary material, which is available to authorized users.

Incidence of invasive pneumococcal disease in immunocompromised patients: A systematic review and meta-analysis

BACKGROUND

Invasive pneumococcal disease (IPD) is associated with high morbidity and mortality, with immunocompromised patients (ICPs) at particular risk. Therefore, guidelines recommend pneumococcal vaccination for these patients. However, guidelines are scarcely underpinned with references to incidence studies of IPD in this population. This, potentially results in unawareness of the importance of vaccination and low vaccination rates. The objective of this systematic review and meta-analysis was to assess the incidence of IPD in ICPs.

METHODS

We systematically searched PubMed and Embase to identify studies in English published before December 6th, 2017 that included terms related to 'incidence', 'rate', 'pneumococcal', 'pneumoniae', 'meningitis', 'septicemia', or 'bacteremia'. We focused on patients with HIV, transplantation and chronic inflammatory diseases.

RESULTS

We included 45 studies in the systematic review reporting an incidence or rate of IPD, defined as isolation of Streptococcus pneumoniae from a normally sterile site. Random effects meta-analysis of 38 studies showed a pooled IPD incidence of 331/100,000 person years in patients with HIV in the late-antiretroviral treatment era in non-African countries, and 318/100,000 in African countries; 696 and 812/100,000 in patients who underwent an autologous or allogeneic stem cell transplantation, respectively; 465/100,000 in patients with a solid organ transplantation; and 65/100,000 in patients with chronic inflammatory diseases. In healthy control cohorts, the pooled incidence was 10/100,000.

DISCUSSION

ICPs are at increased risk of contracting IPD, especially those with HIV, and those who underwent transplantation. Based on our findings, we recommend pneumococcal vaccination in immunocompromised patients.

PROSPERO REGISTRATION

ID: CRD42016048438.

Refining Current Scientific Priorities and Identifying New Scientific Gaps in HIV-Related Heart, Lung, Blood, and Sleep Research

The National Heart, Lung, and Blood Institute (NHLBI) AIDS Program's goal is to provide direction and support for research and training programs in areas of HIV-related heart, lung, blood, and sleep (HLBS) diseases. To better define NHLBI current HIV-related scientific priorities and with the goal of identifying new scientific priorities and gaps in HIV-related HLBS research, a wide group of investigators gathered for a scientific NHLBI HIV Working Group on December 14-15, 2015, in Bethesda, MD. The core objectives of the Working Group included discussions on: (1) HIV-related HLBS comorbidities in the antiretroviral era; (2) HIV cure; (3) HIV prevention; and (4) mechanisms to implement new scientific discoveries in an efficient and timely manner so as to have the most impact on people living with HIV. The 2015 Working Group represented an opportunity for the NHLBI to obtain expert advice on HIV/AIDS scientific priorities and approaches over the next decade.

Impact of a Pharmacy-Initiated HIV Admission Note on Medication Errors within an Academic Hospital

Purpose

Medication errors occur frequently in the medical management of patients infected with human immunodeficiency virus (HIV). Recent studies propose the use of a pharmacy admission note to help identify and prevent such errors during hospitalization. However, a clear reduction in the number of antiretroviral medication errors utilizing an admission note within a large, academic hospital has yet to be confirmed.

Methods

A retrospective, chart-review of hospitalized HIV-seropositive patients 1 year prior to and after implementation of an admission note policy was performed with the expedited Institutional Review Board (IRB) approval. Antiretroviral medication errors were identified and compared to documented pharmacy interventions at the time of admission.

Results

Twenty-seven antiretroviral medication errors existed in the pre-policy period (n = 32 admissions), with no identification or correction by pharmacy services at the time of admission. Forty-six antiretroviral medication errors were detected in the post-policy period (n = 59 admissions), of which three errors were identified in pharmacy admission notes. Common antiretroviral medication errors in the pre-policy period included incorrect dosing frequency (33.3%) and incorrect drug strength (33.3%). This contrasts with the post-policy period, during which the most frequent antiretroviral medication errors included missing antiretroviral components of known regimens (19.6%) and lack of renal or hepatic dosage adjustment (15.2%). Overall, no improvement in detection and reconciliation of medication errors occurred with admission note implementation.

Conclusions

Potential obstacles in the effective use of an admission note to reduce errors do exist. Strategies for improved outcomes in our academic hospital will focus on improved training of general pharmacy staff in HIV management, providing accessible online resources, and emphasizing reconciliation between outpatient and inpatient medication regimens.

HIV Patients in the HCUP Database: A Study of Hospital Utilization and Costs

This study examines the utilization of hospital care by HIV patients in all hospitals in eight states (California, Colorado, Florida, Kansas, New Jersey, New York, Pennsylvania, and South Carolina), and examines the cost of hospital care for HIV patients in six of these states (California, Colorado, Kansas, New Jersey, New York, and South Carolina). The eight states in the sample account for more than 52% of all persons living with AIDS in the United States; the six states account for 39%. The unit of observation in both studies is a hospital admission by a patient with HIV. Hospital data were obtained from the Healthcare Cost and Utilization Project (HCUP), State Inpatient Database (SID), which is maintained by the Agency for Healthcare Research and Quality (AHRQ). The HCUP contains hospital discharge data and is a federal/state/industry partnership to build a multistate health care data system. Using multivariate analytic techniques and data from 2000, results indicate that cost and length of a hospital stay vary significantly across states after accounting for a patient's gender, insurance type, race, age, and number of diagnoses, as well as the teaching status and ownership category of the hospital.

Case Fatality and Health Care Costs in HIV-Infected Patients: Evolution from 1992 to 2000 at Rouen University Hospital, France

Vital prognosis in HIV-infected patients has been improved by new therapies, leading to an increase in treatment and outpatient costs but lower inpatient care costs. The aim of the study was to compare the health care costs between 1992–1996 (first half) and 1996–2000 (second half) in HIV-infected patients at Rouen University Hospital. Hospitalization costs (including inpatient and outpatient care), infectious complication treatment and antiretroviral therapy costs were evaluated from a National Health Insurance viewpoint. Between 1992 and 2000, 1212 patients were admitted at least once. Total expenditure increased between the two periods from €13,660 to €27,567, i.e., a two-fold increase. During the same period, 125 deaths were avoided, and 3602 years of life were gained. The cost of one avoided death was €108,320 and the cost per life-year gained was €3776.

The inextricable axis of targeted diagnostic imaging and therapy: An immunological natural history approach

In considering the challenges of approaches to clinical imaging, we are faced with choices that sometimes are impacted by rather dogmatic notions about what is a better or worse technology to achieve the most useful diagnostic image for the patient. For example, is PET or SPECT most useful in imaging any particular disease dissemination? The dictatorial approach would be to choose PET, all other matters being equal. But is such a totalitarian attitude toward imaging selection still valid? In the face of new receptor targeted SPECT agents one must consider the remarkable specificity and sensitivity of these agents. (99m)Tc-Tilmanocept is one of the newest of these agents, now approved for guiding sentinel node biopsy (SLNB) in several solid tumors. Tilmanocept has a Kd of 3×10(-11)M, and it specificity for the CD206 receptor is unlike any other agent to date. This coupled with a number of facts, that specific disease-associated macrophages express this receptor (100 to 150 thousand receptors), that the receptor has multiple binding sites for tilmanocept (>2 sites per receptor) and that these receptors are recycled every 15 min to bind more tilmanocept (acting as intracellular "drug compilers" of tilmanocept into non-degraded vesicles), gives serious pause as to how we select our approaches to diagnostic imaging. Clinically, the size of SLNs varies greatly, some, anatomically, below the machine resolution of SPECT. Yet, with tilmanocept targeting, the SLNs are highly visible with macrophages stably accruing adequate (99m)Tc-tilmanocept counting statistics, as high target-to-background ratios can compensate for spatial resolution blurring. Importantly, it may be targeted imaging agents per se, again such as tilmanocept, which may significantly shrink any perceived chasm between the imaging technologies and anchor the diagnostic considerations in the targeting and specificity of the agent rather than any lingering dogma about the hardware as the basis for imaging approaches. Beyond the elements of imaging applications of these agents is their evolution to therapeutic agents as well, and even in the neo-logical realm of theranostics. Characteristics of agents such as tilmanocept that exploit the natural history of diseases with remarkably high specificity are the expectations for the future of patient- and disease-centered diagnosis and therapy.

HIV-Related Medical Admissions to a South African District Hospital Remain Frequent Despite Effective Antiretroviral Therapy Scale-Up

The public sector scale-up of antiretroviral therapy (ART) in South Africa commenced in 2004. We aimed to describe the hospital-level disease burden and factors contributing to morbidity and mortality among hospitalized HIV-positive patients in the era of widespread ART availability. Between June 2012 and October 2013, unselected patients admitted to medical wards at a public sector district hospital in Cape Town were enrolled in this cross-sectional study with prospective follow-up. HIV testing was systematically offered and HIV-infected patients were systematically screened for TB. The spectrum of admission diagnoses among HIV-positive patients was documented, vital status at 90 and 180 days ascertained and factors independently associated with death determined. Among 1018 medical admissions, HIV status was ascertained in 99.5%: 60.1% (n = 609) were HIV-positive and 96.1% (n = 585) were enrolled. Of these, 84.4% were aware of their HIV-positive status before admission. ART status was naive in 35.7%, current in 45.0%, and interrupted in 19.3%. The most frequent primary clinical diagnoses were newly diagnosed TB (n = 196, 33.5%), other bacterial infection (n = 100, 17.1%), and acquired immunodeficiency syndrome (AIDS)-defining illnesses other than TB (n = 64, 10.9%). By 90 days follow-up, 175 (29.9%) required readmission and 78 (13.3%) died. Commonest causes of death were TB (37.2%) and other AIDS-defining illnesses (24.4%). Independent predictors of mortality were AIDS-defining illnesses other than TB, low hemoglobin, and impaired renal function. HIV still accounts for nearly two-thirds of medical admissions in this South African hospital and is associated with high mortality. Strategies to improve linkage to care, ART adherence/retention and TB prevention are key to reducing HIV-related hospitalizations in this setting.

HIV disease burden, cost, and length of stay in Portuguese hospitals from 2000 to 2010: a cross-sectional study

BACKGROUND

The number of HIV-related hospitalizations has decreased worldwide in recent years owing to the availability of highly active antiretroviral therapy. However, the change in HIV-related hospitalizations in Portugal has not been studied. Using comprehensive hospital discharge data from mainland Portuguese hospitals, we examined trends in HIV-related inpatient admissions, length of stay (LOS), Elixhauser comorbidity measures, in-hospital mortality, and mean cost from 2000 to 2010.

METHODS

The hospital administrative data from inpatient admissions and discharges at 75 public acute care hospitals in the Portuguese National Health Service from 2000 to 2010 were included. HIV-related admissions were identified using the International Classification of Diseases, 9(th) Revision, Clinical Modification diagnosis codes 042.x-044.x. The effect of Elixhauser comorbidity measures on extending the LOS was assessed by comparing admissions in HIV patients with and without comorbidities using the Mann-Whitney U test. Multivariate logistic regression was performed to estimate the odds of having a decreased discharge.

RESULTS

A total of 57,027 hospital admissions were analyzed; 73% of patients were male, and the mean age was 39 years. The median LOS was 11 days, and the in-hospital mortality was 14%. The mean cost per hospitalization was 5,148.7€. A total of 83% of admissions were through the emergency room. During the period, inpatient HIV admissions decreased by 22%, LOS decreased by 9%, and in-hospital mortality dropped by 12%. Elixhauser comorbidities increased the median LOS in nearly all admissions.

CONCLUSIONS

Despite small regional variations, a strong, consistent decrease was observed in the hospital admission rate, mean cost, length of stay, and mortality rate for HIV-related admissions in Portugal during 2000-2010.

The connection domain mutation N348I in HIV-1 reverse transcriptase enhances resistance to etravirine and rilpivirine but restricts the emergence of the E138K resistance mutation by diminishing viral replication capacity

Clinical resistance to rilpivirine (RPV), a novel nonnucleoside reverse transcriptase (RT) inhibitor (NNRTI), is associated an E-to-K mutation at position 138 (E138K) in RT together with an M184I/V mutation that confers resistance against emtricitabine (FTC), a nucleoside RT inhibitor (NRTI) that is given together with RPV in therapy. These two mutations can compensate for each other in regard to fitness deficits conferred by each mutation alone, raising the question of why E138K did not arise spontaneously in the clinic following lamivudine (3TC) use, which also selects for the M184I/V mutations. In this context, we have investigated the role of a N348I connection domain mutation that is prevalent in treatment-experienced patients. N348I confers resistance to both the NRTI zidovudine (ZDV) and the NNRTI nevirapine (NVP) and was also found to be associated with M184V and to compensate for deficits associated with the latter mutation. Now, we show that both N348I alone and N348I/M184V can prevent or delay the emergence of E138K under pressure with RPV or a related NNRTI, termed etravirine (ETR). N348I also enhanced levels of resistance conferred by E138K against RPV and ETR by 2.2- and 2.3-fold, respectively. The presence of the N348I or M184V/N348I mutation decreased the replication capacity of E138K virus, and biochemical assays confirmed that N348I, in a background of E138K, impaired RT catalytic efficiency and RNase H activity. These findings help to explain the low viral replication capacity of viruses containing the E138K/N348I mutations and how N348I delayed or prevented the emergence of E138K in patients with M184V-containing viruses.

Cost of noninfectious comorbidities in patients with HIV

Objectives

We hypothesized that the increased prevalence of noninfectious comorbidities (NICMs) observed among HIV-infected patients may result in increased direct costs of medical care compared to the general population. Our objective was to provide estimates of and describe factors contributing to direct costs for medical care among HIV-infected patients, focusing on NICM care expenditure.

Methods

A case-control study analyzing direct medical care costs in 2009. Antiretroviral therapy (ART)-experienced HIV-infected patients (cases) were compared to age, sex, and race-matched adults from the general population, included in the CINECA ARNO database (controls). NICMs evaluated included cardiovascular disease, hypertension, diabetes mellitus, bone fractures, and renal failure. Medical care cost information evaluated included pharmacy, outpatient, and inpatient hospital expenditures. Linear regression models were constructed to evaluate predictors of total care cost for the controls and cases.

Results

There were 2854 cases and 8562 controls. Mean age was 46 years and 37% were women. We analyzed data from 29,275 drug prescription records. Positive predictors of health care cost in the overall population: HIV infection (β = 2878; confidence interval (CI) = 2001–3755); polypathology (β = 8911; CI = 8356–9466); age (β = 62; CI = 45–79); and ART exposure (β = 18,773; CI = 17,873–19,672). Predictors of health care cost among cases: Center for Disease Control group C (β = 1548; CI = 330–2766); polypathology (β = 11,081; CI = 9447–12,716); age < 50 years (β = 1903; CI = 542–3264); protease inhibitor exposure (per month of use; β = 69; CI = 53–85); CD4 count < 200 cells/mm³ (β = 5438; CI = 3082–7795); and ART drug change (per change; β = 911; CI = 716–1106).

Conclusion

Total cost of medical care is higher in cases than controls. Lower medical costs associated with higher CD4 strata are offset by increases in the care costs needed for advancing age, particularly for NICMs.

Role of the K101E substitution in HIV-1 reverse transcriptase in resistance to rilpivirine and other nonnucleoside reverse transcriptase inhibitors

Resistance to the recently approved nonnucleoside reverse transcriptase inhibitor (NNRTI) rilpivirine (RPV) commonly involves substitutions at positions E138K and K101E in HIV-1 reverse transcriptase (RT), together with an M184I substitution that is associated with resistance to coutilized emtricitabine (FTC). Previous biochemical and virological studies have shown that compensatory interactions between substitutions E138K and M184I can restore enzyme processivity and the viral replication capacity. Structural modeling studies have also shown that disruption of the salt bridge between K101 and E138 can affect RPV binding. The current study was designed to investigate the impact of K101E, alone or in combination with E138K and/or M184I, on drug susceptibility, viral replication capacity, and enzyme function. We show here that K101E can be selected in cell culture by the NNRTIs etravirine (ETR), efavirenz (EFV), and dapivirine (DPV) as well as by RPV. Recombinant RT enzymes and viruses containing K101E, but not E138K, were highly resistant to nevirapine (NVP) and delavirdine (DLV) as well as ETR and RPV, but not EFV. The addition of K101E to E138K slightly enhanced ETR and RPV resistance compared to that obtained with E138K alone but restored susceptibility to NVP and DLV. The K101E substitution can compensate for deficits in viral replication capacity and enzyme processivity associated with M184I, while M184I can compensate for the diminished efficiency of DNA polymerization associated with K101E. The coexistence of K101E and E138K does not impair either viral replication or enzyme fitness. We conclude that K101E can play a significant role in resistance to RPV.

Cognitive impairment and antiretroviral treatment in a Peruvian population of patients with human immunodeficiency virus

BACKGROUND

HIV-associated cognitive impairment occurs even in the early stages of infection. Short-term memory, psychomotor speed, attention, and executive functioning are the main capacities affected. Controversy exists regarding whether highly active antiretroviral therapy (HAART) is helpful in combating this process. The objective of the present study is to determine the association between cognitive impairment and HAART in HIV-infected patients from Hospital Regional de Huacho.

METHODS

Prospective study of HIV patients meeting criteria to start HAART. Twenty-one HIV-positive patients were recruited between April and July 2011. Researchers administered a standardised neuropsychological test battery before and 4 weeks after onset of HAART. Psychomotor speed, executive function, short term memory (visual and verbal), attention, and visuospatial performance were evaluated.

RESULTS

Nineteen patients completed the study (14 males and 5 females). In the pre-HAART evaluation, most patients scored below average on the executive function and psychomotor speed subtests. Psychomotor speed and immediate visual memory improved significantly after four months of treatment with HAART.

CONCLUSIONS

Some degree of cognitive decline may present even in the early and asymptomatic stages of HIV infection. The benefits of antiretroviral treatment for cognitive performance can be detected after only a few weeks of follow-up.

Impact of antiretroviral therapy on lung immunology and inflammation

Human immunodeficiency virus (HIV) infection causes profound changes in the lung compartment characterized by macrophage and lymphocyte activation, secretion of proinflammatory cytokines and chemokines, and accumulation of CD8 T cells in the alveolar space, leading to lymphocytic alveolitis. Because many of the changes seen in the lung can be attributed to the direct effect of HIV on immune cells, therapy to reduce the HIV burden should have significant beneficial effects. Indeed, antiretroviral therapy rapidly reduces the viral burden in the lung, number of CD8 T cells in the alveolar space, and amount of proinflammatory cytokines and chemokines in bronchoalveolar lavage.

Resource utilization and direct costs of pediatric HIV in Italy

This multicenter, prospective, observational study assessed the global economic impact of HIV care in a large cohort of HIV-infected children and adolescents in Italy. Three pediatric departments of reference participated on a voluntary basis. Centers were asked to enroll all their children during the period April 2010-March 2011. At enrollment, a pediatrician completed a questionnaire for each patient, including the type of service at access (outpatient consultation or day hospital), laboratory tests, instrumental examinations, specialists' consultations, antiretroviral therapy and opportunistic illness prophylaxis. Eligible patients had a confirmed diagnosis of HIV infection caused by direct vertical maternal-fetal transmission, their age ranging from 0 to 24 years. Since patients routinely have quarterly check-ups in all three centers, we adopted a three-month time horizon. Health-care services were priced using outpatient and inpatient tariffs. Drug costs were calculated by multiplying the daily dose by the public price for each active ingredient. A total of 142 patients were enrolled. More than half the patients were female and the mean age was 14 years, with no significant differences by center. There were substantial differences in health-care management among the three centers, particularly as regards the type of access. One center enrolled the majority of its patients in day-hospital and prescribed a large number of clinical tests, while children accessed another center almost exclusively through outpatient consultation. Drug therapy was the main cost component and was very similar in all three centers. The day-hospital was the second highest cost component, much higher than outpatient consultation (including examinations), leading to significant differences between total costs per center. These findings suggest that a recommendation to the Italian National Health Service would be to use more outpatient consultation for patients' access in order to increase their efficiency in treating pediatric HIV infection.

Disparities in receipt of antiretroviral therapy among HIV-infected adults (2002-2008)

OBJECTIVE

Prior research has documented sociodemographic disparities in the use of antiretroviral therapy (ART). Recent therapeutic developments and changing epidemiological profiles may have altered such disparities. We examine the extent to which sociodemographic differences in prescribed ART have changed between 2002 and 2008.

METHODS

We analyzed data abstracted from medical records at 13 US sites participating in the Human Immunodeficiency Virus Research Network. Prescription of ART was assessed for each year in care for each patient. A total of 14,092 patients were followed up for 39,251 person-years. We examined ART use as a function of sex, race/ethnicity, human immunodeficiency virus risk group, age, and CD4 history (no test <500 cells/mm, one or more tests between 500 and 350 cells/mm, 1 test ≤350 cells/mm, and 2 or more tests ≤350 cells/mm). Using multiple logistic regression, we ascertained interactions between each of these variables and calendar year.

RESULTS

The overall percentage prescribed ART increased from 60% to 80% between 2002 and 2008. Among those with 2 or more CD4 tests ≤350 cells/mm, the percentage increased from 82% to 92%. ART rates were higher for those with lower CD4 counts but increased over time for all CD4 groups and for all demographic groups. Nevertheless, sex and racial/ethnic disparities persisted. Significant interactions were obtained for CD4 history by year, age by year, and age by CD4 history.

CONCLUSIONS

Although prescription of ART became more widespread from 2002 to 2008, patients who were female, black, or younger still had lower ART rates than male, white, or older patients.

Compensation by the E138K mutation in HIV-1 reverse transcriptase for deficits in viral replication capacity and enzyme processivity associated with the M184I/V mutations

Recently, several phase 3 clinical trials (ECHO and THRIVE) showed that E138K and M184I were the most frequent mutations to emerge in patients who failed therapy with rilpivirine (RPV) together with two nucleos(t)ide reverse transcriptase inhibitors, emtricitabine (FTC) and tenofovir (TDF). To investigate the basis for the copresence of E138K and M184I, we generated recombinant mutated and wild-type (WT) reverse transcriptase (RT) enzymes and HIV-1(NL4-3) infectious clones. Drug susceptibilities were determined in cord blood mononuclear cells (CBMCs). Structural modeling was performed to analyze any impact on deoxynucleoside triphosphate (dNTP) binding. The results of phenotyping showed that viruses containing both the E138K and M184V mutations were more resistant to each of FTC, 3TC, and ETR than viruses containing E138K and M184I. Viruses with E138K displayed only modest resistance to ETR, little resistance to efavirenz (EFV), and no resistance to either FTC or 3TC. E138K restored viral replication capacity (RC) in the presence of M184I/V, and this was confirmed in cell-free RT processivity assays. RT enzymes containing E138K, E138K/184I, or E138K/184V exhibited higher processivity than WT RT at low dNTP concentrations. Steady-state kinetic analysis demonstrated that the E138K mutation resulted in decreased K(m)s for dNTPs. In contrast, M184I/V resulted in an increased K(m) for dNTPs compared to those for WT RT. These results indicate that the E138K mutation compensates for both the deficit in dNTP usage and impairment in replication capacity by M184I/V. Structural modeling shows that the addition of E138K to M184I/V promotes tighter dNTP binding.

Expenditures for the care of HIV-infected patients in rural areas in China's antiretroviral therapy programs

BACKGROUND

The Chinese government has provided health services to those infected by the human immunodeficiency virus (HIV) under the acquired immunodeficiency syndrome (AIDS) care policy since 2003. Detailed research on the actual expenditures and costs for providing care to patients with AIDS is needed for future financial planning of AIDS health care services and possible reform of HIV/AIDS-related policy. The purpose of the current study was to determine the actual expenditures and factors influencing costs for untreated AIDS patients in a rural area of China after initiating highly active antiretroviral therapy (HAART) under the national Free Care Program (China CARES).

METHODS

A retrospective cohort study was conducted in Yunnan and Shanxi Provinces, where HAART and all medical care are provided free to HIV-positive patients. Health expenditures and costs in the first treatment year were collected from medical records and prescriptions at local hospitals between January and June 2007. Multivariate linear regression was used to determine the factors associated with the actual expenditures in the first antiretroviral (ARV) treatment year.

RESULTS

Five ARV regimens are commonly used in China CARES: zidovudine (AZT) + lamivudine (3TC) + nevirapine (NVP), stavudine (D4T) + 3TC + efavirenz (EFV), D4T + 3TC + NVP, didanosine (DDI) + 3TC + NVP and combivir + EFV. The mean annual expenditure per person for ARV medications was US$2,242 (US$1 = 7 Chinese Yuan (CNY)) among 276 participants. The total costs for treating all adverse drug events (ADEs) and opportunistic infections (OIs) were US$29,703 and US$23,031, respectively. The expenses for treatment of peripheral neuritis and cytomegalovirus (CMV) infections were the highest among those patients with ADEs and OIs, respectively. On the basis of multivariate linear regression, CD4 cell counts (100-199 cells/μL versus <100 cells/μL, P = 0.02; and ≥200 cells/μL versus <100 cells/μL, P < 0.004), residence in Mangshi County (P < 0.0001), ADEs (P = 0.04) and OIs (P = 0.02) were significantly associated with total expenditures in the first ARV treatment year.

CONCLUSIONS

This is the first study to determine the actual costs of HIV treatment in rural areas of China. Costs for ARV drugs represented the major portion of HIV medical expenditures. Initiating HAART in patients with higher CD4 cell count levels is likely to reduce treatment expenses for ADEs and OIs in patients with AIDS.

Contemporary costs of HIV healthcare in the HAART era

BACKGROUND

The delivery of HIV healthcare historically has been expensive. The most recent national data regarding HIV healthcare costs were from 1996-1998. We provide updated estimates of expenditures for HIV management.

METHODS

We performed a cross-sectional review of medical records at 10 sites in the HIV Research Network, a consortium of high-volume HIV care providers across the United States. We assessed inpatient days, outpatient visits, and prescribed antiretroviral and opportunistic illness prophylaxis medications for 14 691 adult HIV-infected patients in primary HIV care in 2006. We estimated total care expenditures, stratified by the median CD4 cell count obtained in 2006 (≤50, 51-200, 201-350, 351-500, >500 cells/μl). Per-unit costs of care were based on Healthcare Cost and Utilization Project (HCUP) data for inpatient care, discounted average wholesale prices for medications, and Medicare physician fees for outpatient care.

RESULTS

Averaging over all CD4 strata, the mean annual total expenditures per person for HIV care in 2006 in three sites was US $19 912, with an interquartile range from US $11 045 to 22 626. Average annual per-person expenditures for care were greatest for those with CD4 cell counts 50 cell/μl or less (US $40 678) and lowest for those with CD4 cell counts more than 500 cells/μl (US $16 614). The majority of costs were attributable to medications, except for those with CD4 cell counts 50 cells/μl or less, for whom inpatient costs were highest.

CONCLUSION

HIV healthcare in the United States continues to be expensive, with the majority of expenditures attributable to medications. With improved HIV survival, costs may increase and should be monitored in the future.

Access to antiretroviral therapy among HIV/AIDS patients in khon kaen province, Thailand

This study attempted to identify the factors associated with the access to antiretroviral therapy (ARV) among HIV/AIDS patients in Khon Kaen Province, Thailand. We collected medical and sociodemographic data from the medical charts of adult patients living in the province who received medical services at two public hospitals in the province. The study period was from December 1, 2001 to February 28, 2002. Total 593 outpatients were included in the analysis. One hundred and forty-six patients (24.6%) received ARV. A logistic regression analysis was conducted to identify the factors associated with the use of ARV. Patients who were covered by the Civil Servant Medical Benefit Scheme were significantly more likely to receive ARV than those who were covered by the Universal Coverage Scheme (UC), a publicly-funded medical insurance (OR = 12.43; 95% CI = 6.03-25.62). The results of this study indicated that there were inequalities in access to and use of ARV among HIV/AIDS patients by health insurance status. The current government announced that they would include ARV in the benefits package of UC. It would be important to monitor how this policy will improve the access to ARV among HIV/AIDS patients.

Health-related quality of life and patient–provider relationships in HIV-infected patients during the first three years after starting PI-containing antiretroviral treatment

The aim of this study was to investigate factors associated with better health-related quality of life (HRQL) during the first three years after starting PI-containing antiretroviral treatment. Clinical, social and behavioural data from the APROCO cohort enabled us to analyze simultaneously the association between HRQL and patients' relationships with their health care providers. A self-administered questionnaire collected information about HRQL (MOS-SF36) and relationships with medical staff (trust and satisfaction with information). Two aggregate scores, the physical (PCS) and mental (MCS) component summaries (adjusted for baseline HRQL), were used as dependent variables in the linear regressions to identify factors associated with HRQL. We had complete longitudinal data for 360 of the 611 patients followed through M36. Factors independently associated with a high MCS were (male) gender, no more than one change in treatment, (few) self-reported symptoms and trust in the physician. Factors independently associated with high PCS levels were employment, no children, (few) self-reported symptoms and satisfaction with the information and explanations provided by the medical staff. These results underline the need to improve patient-provider relationships to optimize long-term HRQL. Socio-behavioural interventions should focus on this goal.

Development of a nonintegrating Rev-dependent lentiviral vector carrying diphtheria toxin A chain and human TRAF6 to target HIV reservoirs

Persistence of HIV despite highly active antiretroviral therapy (HAART) is a lasting challenge to virus eradication. To develop a strategy complementary to HAART, we constructed a series of Rev-dependent lentiviral vectors carrying diphtheria toxin A chain (DT-A) and its attenuated mutants, as well as human TRAF6. Expression of these suicide genes following delivery through viral particles is dependent on Rev, which exists only in infected cells. Among these toxins, DT-A has been known to trigger cell death with as little as a single molecule, whereas two of the attenuated mutants in this study, DT-A(176) and DT-A(ΔN), were well-tolerated by cells at low levels. TRAF6 induced apoptosis only with persistent overexpression. Thus, these suicide genes, which induce cell death at different expression levels, offer a balance between efficacy and safety. To minimize possible mutagenesis introduced by retroviral integration in non-target cells, we further developed a non-integrating Rev-dependent (NIRD) lentiviral vector to deliver these genes. In addition, we constructed a DT-A-resistant human cell line by introducing a human elongation factor 2 (EF-2) mutant into HEK293T cells. This allowed us to manufacture the first high-titer NIRD lentiviral particles carrying DT-A to target HIV-positive cells.

Inpatient health services utilization among HIV-infected adult patients in care 2002-2007

OBJECTIVE

This study examines the frequency of inpatient hospitalization, the number of inpatient days, and factors associated with inpatient utilization in a multistate HIV cohort between 2002 and 2007.

DESIGN

A prospective cohort study of HIV-infected adults in care at 11 US HIV primary and specialty care sites located in different geographic regions.

METHODS

Demographic, clinical, and resource utilization data were collected from medical records for the years 2002-2007. Rates of resource use were calculated for number of hospital admissions, total inpatient days, and mean length of stay per admission.

RESULTS

Annual inpatient hospitalization rates significantly decreased from 35 to 27 per 100 persons from 2002 to 2007. The number of inpatient days per year significantly decreased over time, whereas mean length of stay per admission was stable. Women, patients 50 years or older, blacks, injection drug users, and patients without private insurance had higher hospitalization rates than their counterparts. Admission rates were lower for patients with high CD4 counts and low HIV-1 RNA levels.

CONCLUSIONS

Inpatient hospitalization rates and number of inpatient days decreased for HIV patients in this multistate cohort between 2002 and 2007. Sociodemographic disparities in inpatient utilization persist.

Evaluation of affordable screening markers to detect CD4+ T-cell counts below 200 cells/mul among HIV-1-infected Ugandan adults

OBJECTIVE

To evaluate validity of WHO staging, low body mass index (BMI) and anaemia in detecting HIV-infected adults with CD4+ T-cell counts < 200 cells/microl.

METHODS

Between October 1995 and April 2006, we screened Ugandans aged 16 or older at enrollment into an open cohort. We analysed highly active anti-retroviral therapy (HAART)-naïve HIV-infected patients with WHO stages 1-3 and complete data in a secondary cross-sectional study. Low BMI was a BMI < 18.5 kg/m(2). Anaemia was a haemoglobin level < 11 or 12 g/dl among women and men respectively.

RESULTS

Among 2892 HAART-naïve patients, the median age was 32 years. 71% were women, 54% had WHO stage 3 AIDS, 34% had anaemia, 16% had a low BMI and 43% had CD4+ T-cell counts < 200 cells/microl. WHO stage 3 compared to combined WHO stages 1 and 2 had a sensitivity (95% CI) of 70% (67, 72) and a specificity of 57% (55, 60) respectively to detect CD4+ T-cell counts < 200 cells/microl. Anaemia compared to normal haemoglobin had sensitivity (95% CI) of 47% (44, 50) and a specificity of 76% (74, 78). Low BMI compared to normal BMI had sensitivity (95% CI) of 23% (20, 25) and a specificity of 89% (87, 90) against CD4+ T-cell counts < 200 cells/microl.

CONCLUSION

Only WHO stage 3 had reasonably high sensitivity in detecting CD4+ T-cell counts below 200 cells/microl in this setting. Targeted low-cost CD4 testing strategies are urgently needed to detect patients eligible for HAART in rural Africa and other resource-limited settings.

Emergency department utilization among HIV-infected patients in a multisite multistate study

OBJECTIVE

The aim of this study was to examine Emergency Department (ED) utilization and clinical and sociodemographic correlates of ED use among HIV-infected patients.

METHODS

During 2003, 951 patients participated in face-to-face interviews at 14 HIV clinics in the HIV Research Network. Respondents reported the number of ED visits in the preceding 6 months. Using logistic regression, we identified factors associated with visiting the ED in the last 6 months and admission to the hospital from the ED.

RESULTS

Thirty-two per cent of respondents reported at least one ED visit in the last 6 months. In multivariate analysis, any ED use was associated with Medicaid insurance, high levels of pain (the third or fourth quartile), more than seven primary care visits in the last 6 months, current or former illicit drug use, social alcohol use and female gender. Of those who used ED services, 39% reported at least one admission to the hospital. Patients with pain in the highest quartile reported increased admission rates from the ED as did those who made six or seven primary care visits, or more than seven primary care visits vs. three or fewer.

CONCLUSIONS

The likelihood of visiting the ED has not diminished since the advent of highly active antiretroviral therapy (HAART). More ED visits are to treat illnesses not related to HIV or injuries than to treat direct sequelae of HIV infection. With the growing prevalence of people living with HIV infection, the numbers of HIV-infected patients visiting the ED may increase, and ED providers need to understand potential complications produced by HIV disease.

The concurrent validity and responsiveness of the health utilities index (HUI 3) among patients with advanced HIV/AIDS

OBJECTIVES

To assess the concurrent validity and responsiveness of the Health Utility Index 3 (HUI3) in patients with advanced HIV/AIDS, and to determine the responsiveness of this measure, the MOS-HIV and EQ-5D to HIV-related clinical events.

METHODS

Data from the OPTIMA (OPTions In Management with Antiretrovirals) trial was analyzed. Two aspects of the validity of the HUI3 were considered: concurrent validity was evaluated using Spearman correlations with MOS-HIV component and summary scores. Responsiveness to AIDS-defining events (ADE) and all adverse events (our external change criterion) was assessed using area under the receiver operating characteristic (AUROC) curves.

RESULTS

The study enrolled 368 patients (mean follow-up: 3.66 years); 82% had at least one severe adverse event and 27% had at least one ADE. The HUI3 scale and items showed good concurrent validity, with 85% of the expected relationships with the MOS-HIV subscales verified. The HUI3 was responsive to both adverse events (AUROC [95%CI]: 0.68 [0.57, 0.80]) and ADEs (0.62 [0.51, 0.74]). The EQ-5D was responsive to ADEs (0.66 [0.56, 0.76]), but not responsive to adverse events (0.56 [0.46, 0.68]).

CONCLUSION

The HUI3 is a valid and responsive measure of the change in HRQoL associated with clinical events in an advanced HIV/AIDS population.

[Evaluation of the status of patients with severe infection, criteria for intensive care unit admittance. Spanish Society for Infectious Diseases and Clinical Microbiology. Spanish Society of Intensive and Critical Medicine and Coronary Units]

Recent studies have shown that early attention in patients with serious infections is associated with a better outcome. Assistance in intensive care units (ICU) can effectively provide this attention; hence patients should be admitted to the ICU as soon as possible, before clinical deterioration becomes irreversible. The objective of this article is to compile the recommendations for evaluating disease severity in patients with infections and describe the criteria for ICU admission, updating the criteria published 10 years ago. A literature review was carried out, compiling the opinions of experts from the Sociedad Española de Enfermedades Infecciosas y Microbiología Clínica (SEIMC, Spanish Society for Infectious Diseases and Clinical Microbiology) and the Sociedad Española de Medicina Intensiva, Crítica y Unidades Coronarias (SEMICYUC, Spanish Society for Intensive Medicine, Critical Care and Coronary Units) as well as the working groups for infections in critically ill patients (GEIPC-SEIMC and GTEI-SEMICYUC). We describe the specific recommendations for ICU admission related to the most common infections affecting patients, who will potentially benefit from critical care. Assessment of the severity of the patient's condition to enable early intensive care is stressed.

Trends in hospitalizations for AIDS-associated Pneumocystis jirovecii Pneumonia in the United States (1986 to 2005)

BACKGROUND

Although hospitalizations for AIDS-associated Pneumocystis jirovecii pneumonia (PCP) in the United States have decreased since the introduction of chemoprophylaxis and potent combination antiretroviral therapy (ART), PCP remains an important cause of illness and death among AIDS patients.

METHODS

We analyzed trends in AIDS-associated PCP hospital discharges using the National Hospital Discharge Surveys between 1986 and 2005.

RESULTS

An estimated 539 million patients were discharged from hospitals between 1986 and 2005, of whom an estimated 312,411 had AIDS-associated PCP. The proportion of patients discharged from the hospital with AIDS-associated PCP decreased from 31% before the introduction of chemoprophylaxis (1986 to 1989) to 17% with chemoprophylaxis (1990 to 1995) and subsequently to 9% after the introduction of ART in 1996 (p < 0.001). Mortality from AIDS-associated PCP decreased from 21 to 16% and subsequently to 7% between these three time periods (p < 0.001). Among those who received mechanical ventilation, mortality decreased from 79% in the prechemoprophylaxis era to 31% in the ART era (p < 0.001) alongside an increase (from 5 to 11%) in the use of mechanical ventilation. We also observed a shift in the population at-risk for PCP over time: a greater proportion of black people, women, and people from Southern states were affected (all p < 0.001).

CONCLUSIONS

While there have been significant reductions in hospitalizations and hospital mortality for AIDS-associated PCP over the last 20 years, these reductions have not been homogenous across demographic subpopulations and geographic regions and point to new at-risk populations. Furthermore, mortality in severe cases of PCP that require mechanical ventilation has improved substantially.

Structures of care in the clinics of the HIV Research Network

As the HIV epidemic has evolved to become a chronic, treatable condition the focus of HIV care has shifted from the inpatient to the outpatient arena. The optimal structure of HIV care in the outpatient setting is unknown. Using the HIV Research Network (HIVRN), a federally sponsored consortium of 21 sites that provide care to HIV-infected individuals, this study attempted to: (1) document key features of the organization of care in HIVRN adult clinics and (2) estimate variability among clinics in these parameters. A cross-sectional survey of adult clinic directors regarding patient volume, follow-up care, provider characteristics, acute patient care issues, wait times, patient safety procedures, and prophylaxis practices was conducted from July to December 2007. All 15 adult HIVRN clinic sites responded: 9 academic and 6 community-based. The results demonstrate variability in key practice parameters. Median (range) of selected practice characteristics were: (1) annual patient panel size, 1300 (355-5600); (2) appointment no-show rate, 28% (8%-40%); (3) annual loss to follow-up, 15% (5%-25%); (4) wait time for new appointments, 5 days (0.5-22.5), and follow-up appointment, 8 days (0-30). The majority of clinics had an internal mechanism to handle acute patient care issues and provide a number of onsite consultative services. Nurse practitioners and physician assistants were highly utilized. These data will facilitate improvements in chronic care management of persons living with HIV.

Incremental drug treatment cost in HIV-positive patients in industry-sponsored clinical trials

BACKGROUND

Drugs used in clinical trials supported by the pharmaceutical industry are supplied free of charge by the companies. However, maintenance of treatment with those drugs when the trials have finished can generate extra cost for patients who participated in the trials.

OBJECTIVE

To assess whether HIV-infected patients' participation in clinical trials results in drug cost savings or increases.

METHODS

An analysis of all antiretrovirals dispensed to HIV-infected outpatients prior to, during, and after their participation in clinical trials in a university hospital during a 2-year period was conducted. Only patients who completed the trial during the study period were included. The following outcomes were measured: (1) cost saved (difference between cost per day during the trial and cost per day before study entry), (2) cost generated (difference between cost per day at the end of the trial and cost per day before study entry), (3) balance between cost saved and cost generated, and (4) number of days that a patient received a drug once the trial was finished to generate cost, considering costs saved. All data were extracted from the hospital pharmacy database. A stratified analysis by type of clinical trial (ordinary or expanded use) was undertaken.

RESULTS

Data from 61 patients were analyzed. The cost of drug therapy during patient participation in a clinical trial was lower than the cost prior to inclusion. Therefore, mean drug savings of $10.38 (US) per patient day resulted (95% CI -5.9 to 14.84). The mean cost generated was $8.74 per patient day (95% CI 3.95 to 13.52).

CONCLUSIONS

A patient's participation in a clinical trial or expanded-access clinical trial generated extra cost once the trial had finished because the cost of drug therapy was higher at the end of the study. In our study, the daily drug costs saved during the trial were similar to the daily drug costs generated.

Selective killing of HIV-1-positive macrophages and T cells by the Rev-dependent lentivirus carrying anthrolysin O from Bacillus anthracis

Background

The ability of Human Immunodeficiency Virus (HIV) to persist in the body has proven to be a long-standing challenge to virus eradication. Current antiretroviral therapy cannot selectively destroy infected cells; it only halts active viral replication. With therapeutic cessation or interruption, viral rebound occurs, and invariably, viral loads return to pre-treatment levels. The natural reservoirs harboring replication-competent HIV-1 include CD4 T cells and macrophages. In particular, cells from the macrophage lineage resist HIV-1-mediated killing and support sustained viral production. To develop a complementary strategy to target persistently infected cells, this proof-of-concept study explores an HIV-1 Rev-dependent lentiviral vector carrying a bacterial hemolysin, anthrolysin O (anlO) from Bacillus anthracis, to achieve selective killing of HIV-1- infected cells.

Results

We demonstrate that in the Rev-dependent lentiviral vector, anlO expression is exclusively dependent on Rev, a unique HIV-1 protein present only in infected cells. Intracellular expression and oligomerization of AnlO result in membrane pore formation and cytolysis. We have further overcome a technical hurdle in producing a Revdependent AnlO lentivirus, through the use of β-cyclodextrin derivatives to inhibit direct killing of producer cells by AnlO. Using HIV-1-infected macrophages and T cells as a model, we demonstrate that this Rev-dependent AnlO lentivirus diminishes HIV-1- positive cells.

Conclusion

The Rev-dependent lentiviral vector has demonstrated its specificity in targeting persistently infected cells. The choice of anlO as the first suicidal gene tested in this vector is based on its cytolytic activity in macrophages and T cells. We conclude that Rev-regulated expression of suicidal genes in HIV-1-positive cells is possible, although future in vivo delivery of this system needs to address numerous safety issues.

Associations between outpatient and inpatient service use among persons with HIV infection: a positive or negative relationship?

OBJECTIVE

To examine the prospective association between frequency of outpatient visits and subsequent inpatient admissions.

DATA SOURCES

Medical record data on 13,942 patients with HIV infection seen in 10 HIV speciality care sites across the United States.

STUDY DESIGN

This observational study followed a cohort of HIV-infected patients who were in care in the first half of 2001. Numbers of inpatient admissions and outpatient visits were calculated for each patient for each 3-month period, from 2001 through 2004.

ANALYSIS

Negative binomial and logistic regression analyses using random-effects models examined the effects of inpatient admissions and outpatient visits in the previous period on inpatient and outpatient service utilization, controlling for background characteristics and HIV disease stage.

RESULTS

For 3-month periods, between 5 and 9 percent of patients had an inpatient admission. The linear association between number of outpatient visits and any inpatient admission in the subsequent period was positive (adjusted odds ratio=1.05; 95 percent confidence interval [CI]=1.04, 1.06). However, patients with zero prior outpatient visits had significantly greater admission rates than those with one prior visit. Hospitalization rates were also higher among those with a prior hospitalization and those with more advanced HIV disease.

CONCLUSIONS

These results suggest a J-shaped relationship between outpatient use and inpatient use among persons with HIV disease. Those in worse health have greater utilization of both inpatient and outpatient care. However, having no outpatient visits may also increase the likelihood of subsequent hospitalization. Although outpatient care cannot be justified as a cost-saving mechanism, maintaining regular clinical monitoring of patients is important.

Current status of HIV infection: a review for non-HIV-treating physicians

An estimated 40 million people live with human immunodeficiency virus (HIV) globally, and over four million people were newly diagnosed with HIV infection in 2006. Twenty-five million people have died as a result of HIV since its recognition in 1981. Where available, highly active antiretroviral therapy has resulted in significant decreases in HIV-associated morbidity and mortality. Nevertheless, opportunistic infections and conditions continue to occur, and their recognition and management continue to be an important component of HIV care.

Longitudinal assessment (1995-2003) of hospitalizations of HIV-infected patients within a geographical population in Canada

OBJECTIVES

To determine the frequency of and reasons for hospitalization of adult HIV-infected patients compared with the general population.

METHODS

Length of stay, primary/secondary diagnoses and discharge status were reviewed for all HIV-infected patients admitted to Calgary-area hospitals between 1995 and 2003. Admissions were classified as HIV- or non-HIV-related using International Classification of Diseases, 9th and 10th revisions (ICD-9/10) codes and confirmed by chart review. Summary comparative data on admissions for the general population were obtained from the regional administrative database.

RESULTS

HIV-infected adults were hospitalized more than twice as frequently, experienced longer stays (median length 5 vs 3 days, respectively) and had higher in-hospital mortality rates (9.1 vs 1.3 per 100 admissions, respectively) than the general population (P < 0.01). Hospitalizations of HIV-infected patients declined by 58% from 1995 to 2003. Patients newly diagnosed with HIV infection accounted for 15% of all HIV-related hospitalizations. HIV-related admissions for known HIV-infected patients decreased from 12 per 100 patient-years-followed in 1995 to 3 per 100 patient-years-followed in 2003. Low CD4 counts, AIDS, and no current use of highly active antiretroviral therapy (HAART) were strongly correlated with hospitalizations (P < 0.01). Non-HIV-related hospitalizations for HIV-infected patients increased by 42% and were associated with comorbidities (e.g. substance use and psychological disorders).

CONCLUSION

Despite the reduction in HIV-related hospitalizations following the introduction of HAART, all-cause hospitalization rates have increased and have started to erode this benefit.

HIV-Related Lung Disorders

Highly active antiretroviral therapy (HAART) has dramatically altered the spectrum of morbidity and mortality in HIV-infected patients. This has been attributed to improvements in the lung microenvironment leading to enhanced pulmonary immunity, either by preventing the progressive loss of immune function or by actually promoting immune restoration. However, these changes have been accompanied by the recognition of new pulmonary complications in HIV-infected subjects, especially those associated with immune reconstitution. In this review we will describe how HIV infection alters the normal pulmonary environment, highlight the effect of HAART on these perturbations, and discuss potential complications of HAART in the lung, focusing on the pulmonary immune reconstitution inflammatory syndrome.

Early initiation of antiretroviral therapy: the current best way to reduce liver-related deaths in HIV/hepatitis C virus-coinfected patients

Approximately 25% to 35% of HIV-infected persons in developed countries are coinfected with hepatitis C virus (HCV). HCV liver disease is accelerated by HIV coinfection, especially at low CD4 cell counts. Highly active antiretroviral therapy (HAART) dramatically reduces HIV-related mortality, and liver disease has emerged as a major cause of death in HIV/HCV-coinfected persons. Anti-HCV therapy with pegylated interferon plus ribavirin can cure HCV infection in up to 40% of coinfected patients; however, only approximately 10% of coinfected patients are considered candidates. Hence, HCV therapy cures approximately 4% of coinfected patients. Eleven cohort studies have shown that HAART is associated with a reduced rate of progression of HCV liver disease, and 4 of these studies have demonstrated a reduction in liver-related mortality. Although offering HCV therapy to the few eligible HIV/HCV-coinfected patients is important, early initiation of HAART in coinfected patients has a greater public health impact in reducing liver-related mortality than in curing HCV infection in approximately 4% of these patients.

[Recommendations from the GESIDA/Spanish AIDS Plan regarding antiretroviral treatment in adults with human immunodeficiency virus infection (update January 2007)]

OBJECTIVE

This consensus document is an update of antiretroviral therapy (ART) recommendations for adult patients infected with the human immunodeficiency virus (HIV-1).

METHODS

To formulate these recommendations, a panel composed of members of the Grupo de Estudio de Sida (GESIDA; AIDS Study Group) and the Plan Nacional sobre el Sida (PNS; Spanish AIDS Plan) reviewed the advances in the current understanding of the pathophysiology of HIV, the safety and efficacy findings from clinical trials, and the results from cohort and pharmacokinetic studies published in biomedical journals or presented at scientific meetings over the last years. Three levels of evidence were defined according to the source of the data: randomized studies (level A), cohort or case-control studies (level B), and expert opinion (level C). The decision to recommend, consider or not recommend ART was established in each situation.

RESULTS

Currently, the treatment of choice for chronic HIV infection is the combination of three drugs of two different classes, including 2 nucleosides or nucleotide analogs (NRTI) plus 1 non-nucleoside (NNRTI) or 1 boosted protease inhibitor (PI/r). Initiation of ART is recommended in patients with symptomatic HIV infection. In asymptomatic patients, initiation of ART is recommended on the basis of CD4+ lymphocyte counts and plasma viral load, as follows: 1) therapy should be started in patients with CD4+ counts of < 200 cells/microl; 2) therapy should be started in most patients with CD4+ counts of 200-350 cells/microl, although it can be delayed when CD41 count persists at around 350 cells/microL and viral load is low, and 3) initiation of therapy can be delayed in patients with CD4+ counts of > 350 cells/microL. The initial objective of ART is to achieve an undetectable viral load. Adherence to therapy plays an essential role in maintaining the antiviral response. Therapeutic options are limited with the development of cross resistance and ART failure. Genotype studies are useful in these cases. More information regarding the studies analyzed and the panel recommendations for adherence, toxicity, treatment during pregnancy, patients with hepatitis B or C virus co-infection, and post-exposure prophylaxis can be accessed at www.gesida.seimc.org.

CONCLUSIONS

CD4+ lymphocyte count is the most important reference factor for initiating ART in asymptomatic patients. The large number of available drugs, the increased sensitivity of tests to monitor viral load, and the ability to determine viral resistance is leading to a more individualized approach to therapy.

Access to HAART and utilization of inpatient medical hospital services among HIV-infected patients with co-occurring serious mental illness and injection drug use

OBJECTIVE

Among HIV-infected individuals, we examined whether having co-occurring serious mental illness (SMI) and injection drug use (IDU) impacts: (a) receipt of highly active antiretroviral therapy (HAART), and (b) utilization of inpatient HIV services, compared to those who have SMI only, IDU only or neither SMI nor IDU.

METHOD

Demographic, clinical and resource utilization data were collected from medical records of 5119 patients in HIV primary care at four US HIV care sites in different geographic regions with on-site mental health services in 2001. We analyzed receipt of HAART using multivariate logistic regression and the number of medical hospital admissions using multivariate logistic and Poisson regression analyses, which controlled for demographic factors, receipt of HAART, CD4 count and HIV-1 RNA.

RESULTS

Those with co-occurring SMI and IDU [adjusted odds ratio (AOR)=0.52; 95% confidence interval (95% CI)=0.41-0.81] and those with IDU alone (AOR=0.64; 95% CI=0.58-0.85) were significantly less likely to receive HAART than those with neither SMI nor IDU, controlling for demographic and clinical factors. Those with co-occurring SMI and IDU were more likely to use any inpatient medical services (AOR=2.22; 95% CI=1.64-3.01) and were significantly more likely to use them more frequently (incidence rate ratio=1.33; 95% CI=1.13-1.55) than those with neither SMI nor IDU, SMI only or IDU only.

CONCLUSION

HIV-infected individuals with co-occurring SMI and IDU are significantly more likely to utilize HIV-related medical inpatient services than individuals with no comorbidity or with only one comorbidity. Individuals with both SMI and IDU did not differ from those with IDU only in receipt of HAART. Inpatient hospitalizations are expensive, and efforts should be targeted towards these populations to reduce potentially avoidable inpatient care.

Actividad enzimática extracelular en Cryptococcus neoformans en diferentes países

Three hundred and ten Cryptococcus neoformans strains isolated from AIDS patients in five different countries (151 from Brazil, 23 from Italy, 28 from Spain, 104 from Thailand and four from Turkey) were tested by the API-ZYM kit to detect their extracellular enzymatic activity. The enzymes esterase (C4) (no 3), esterase lipase (C8) (no 4), leucine arylamidase (no 6) and acid phosphatase (no 11) were commonly positive in most of the strains (more than 95%). These enzymes could be considered a useful tool not only for C. neoformans identification, but in particular for their possible relationship to new C. neoformans virulence factors and also for epidemiological research. Interestingly, it is also the high positive percentage of alpha-glucosidase and beta-glucosidase detected in all isolates. The serotype A was the most predominant serotype in all countries, except for Italy where the serotype D was predominant. Further studies are needed to draw a clear correlation between the API-ZYM profile and serotype.

Current status of antiretroviral therapy

At present, there are 22 FDA-approved antiretroviral agents, which are categorised into four classes of drugs. Several others are in various stages of basic and clinical development. The authors of this paper review the general characteristics of each class of antiretrovirals, as well as individual investigational agents that are in advanced clinical development. A brief synopsis of US and WHO antiretroviral treatment guidelines is also provided.

Hospitalization trends among children and youths with perinatal human immunodeficiency virus infection, 1990-2002

BACKGROUND

Major improvements in disease progression among HIV-infected children have followed the adoption of combination antiretroviral therapy.

METHODS

We examined trends in hospitalization rates between 1990-2002 among 3,927 children/youths with perinatal HIV infection, ranging in age from newborn to 21 years. We used Poisson regression to test for trends in hospitalization rates by age and year; binomial regression to test for trends in intensive care unit (ICU) admissions and hospitalization at least once and more than once, by age and year; and multivariate logistic regression to examine factors associated with hospitalization, ICU admission, and hospitalization longer than 10 days.

RESULTS

Statistically significant downward trends in hospitalization rates and multiple hospitalizations were observed in all age groups from 1990-2002. The proportion of HIV-infected children/youths who were hospitalized at least once declined from 30.4% in 1990 to 12.9% in 2002, with a steady decline occurring after 1996, when the U.S. Public Health Service issued guidelines recommending triple-drug antiretroviral therapy (triple therapy) for HIV-infected children. ICU admissions declined significantly in all age groups except among children younger than 2 years. Logistic regression results indicated that black and Hispanic children/youths were significantly more likely to be hospitalized than white children/youths and that children/youths receiving triple therapy were significantly more likely to be hospitalized than therapy-naive children; the latter association was not observed among children monitored from 1997-2002.

CONCLUSIONS

Substantial reductions in rates of hospitalization, multiple hospitalizations, and ICU admission have occurred among HIV-infected children/youths from 1990-2002, particularly after 1996, with increased use of triple therapy.