Primary Care Guidelines for the Management of Persons Infected with Human Immunodeficiency Virus: Recommendations of the HIV Medicine Association of the Infectious Diseases Society of America

Limited preventive care among Medicaid enrollees with HIV in the US South

Routine preventive care (RPC) services are recommended for people with HIV, who have higher risk of certain preventable conditions. We used a pooled cross-section of patient-years to examine receipt of 5 annual RPC services among Medicaid enrollees in the US South. Data were person-level administrative claims (Medicaid Analytic eXtract, 2008-2012) and county-level characteristics for 16 Southern states plus District of Columbia. Generalized estimating equations estimated the probability of lipid, glucose, syphilis, and cervical cancer (women only) screenings and influenza vaccination. We also examined service receipt among subgroups including enrollees requiring more general or HIV-specific care, in managed care, < 45 years and, separately, Non-Hispanic Black and Non-Hispanic White enrollees. The sample included 57,695 adult Medicaid enrollees with HIV (187,275 enrollee-years) that were majority 45-54 years (38.0%), female (53.6%), Non-Hispanic Black (54.3%), and urban (90.2%). Enrollees received lipid, syphilis, and cervical cancer screenings and influenza vaccination in < 50% and glucose screening in 71.7% of total enrollment-years. The adjusted probability was low (< 50%) for all services except glucose screening (estimated probability 81%; 95% confidence interval 78%, 83%). Findings were similar across subgroups. There is consistent, suboptimal receipt of RPC services among people with HIV. Approaches are needed to increase uptake of RPC services.

Development and performance of a point-of-care rapid antigen test for detection of SARS-COV-2 variants

Background

SARS-CoV-2 antigen-based tests are well-calibrated to infectiousness and have a critical role to play in the COVID-19 public health response. We report the development and performance of a unique lateral flow immunoassay (LFA).

Methods

Combinations of several monoclonal antibodies targeting multiple antigenic sites on the SARS-CoV-2 nucleocapsid protein (NP) were isolated, evaluated, and chosen for the development of a LFA termed CoV-SCAN (BioMedomics, Inc.). Clinical point-of-care studies in symptomatic and asymptomatic individuals were conducted to evaluate positive predictive agreement (PPA) and negative predictive agreement (NPA) with RT-PCR as comparator.

Results

In laboratory testing, CoV-SCAN detected 14 recombinant N-proteins of SARS-CoV-2 variants with sensitivity in the range of 0.2-3.2 ng/mL, and 10 authentic SARS-CoV-2 variants with sensitivity in the range of 1.6-12.5 TCID50/swab. No cross reactivity was observed with other human coronaviruses or other respiratory pathogens. In clinical point-of-care testing on 148 individuals over age 2 with symptoms of ≤5 days, PPA was 87.2% (CI 95: 78.3-94.8%) and NPA was 100% (CI 95: 94.2-100%). In another 884 asymptomatic individuals, PPA was 85.7% (CI 95: 42.1-99.6%) and 99.7% (99.0-99.9%). Overall, CoV-SCAN detected over 97.2% of specimens with CT values <30 and 93.8% of nasal swab specimens with the Omicron variant, even within the first 2 days after symptom onset.

Conclusions

The unique construction of CoV-SCAN using two pairs of monoclonal antibodies has resulted in a test with high performance that remains durable across multiple variants in both laboratory and clinical evaluations. CoV-SCAN should identify almost all individuals harboring infectious SARS-CoV-2.

Summary

Unique construction of a point-of-care rapid antigen test using two pairs of monoclonal antibodies has led to good performance that remained durable across multiple variants in laboratory and clinical evaluations. Test should identify almost all individuals harboring infectious SARS-CoV-2.

Biomarkers and Prevalence of Cardiometabolic Syndrome Among People Living With HIV/AIDS, Addis Ababa, Ethiopia: A Hospital-Based Study

BACKGROUND

While the fast extension of combination antiretroviral therapy (cART) has resulted in significant increases in life expectancy, disorders such as cardiometabolic syndrome (CMetS), which have received less attention, are becoming a major concern in HIV/AIDS patients (PLWHA).

OBJECTIVES

The purpose of this research was to identify biomarkers and determine the prevalence of CMetS in PLWHA using the National Cholesterol Education Program (NCEP) and the International Diabetes Federation (IDF) tools.

METHODS

Between January 2019 and February 2021, a hospital-based study of HIV-infected patients (n = 288) was conducted. The data were analyzed using binary logistic regression. To control the effect of confounders, independent variables with a P-value of <.20 in the bivariate logistic regression were incorporated into multivariate logistic regression. Statistical significance was defined as a 95% confidence interval and a P-value of less than .05.

RESULTS

The risk of CMetS increased twofold as age increased each year (P = .009), 1.2 times as the age at which cART began increased (P = .015), and 6 times with 1 or more co-morbidities (P = .028), according to the NCEP tool. Furthermore, significant NCEP-CMetS correlations were produced by a rise in diastolic blood pressure (P < .001) and cART duration (P = .006). Male gender was 99.9% less likely to be related to CMetS using the IDF tool, and the risk of CMetS increased fourfold with each unit increase in waist circumference (P < .001). Triglycerides and blood type "A" have been found to have substantial relationships with CMetS using both techniques.

CONCLUSION

According to the study, CMetS was found to be common in PLWHA. Age, time on cART, age when cART started, gender, co-morbidities, waist circumference, and diastolic blood pressure were all revealed to be significant predictors of CMetS. Triglycerides and blood type "A" were the only biomarkers found to be significant with CMetS using both the NCEP and IDF tools.

Knowledge, attitude and practice towards hepatitis B infection among high school students in Asante Mampong, Ghana

BACKGROUND

Hepatitis B virus (HBV) infection is a serious global public health problem, with significant morbidity and mortality from acute and chronic complications. Increasing awareness and improving knowledge of HBV helps reduce the risk of the disease. Although many studies have been conducted on HBV in Ghana, few have focused on examining knowledge, attitude and preventive practices among adolescents towards the disease.

OBJECTIVE

The objective of this study was to assess HBV knowledge, attitude and practice (KAP) among adolescents in high schools in the Asante Mampong Municipality in the Ashanti Region of Ghana.

METHODS

A descriptive cross-sectional study was conducted among 398 adolescents from six senior high schools within the Asante Mampong Municipality. Data was collected using a 30-item structured questionnaire. Each item had two response options: "Yes" and "No". A scoring system was generated and respondents were given a score on each item answered. A positive response to an item was scored 1 point and a negative response was scored 0. Scores were then summed up and averaged to give the mean knowledge, attitude and practice scores.

RESULTS

The majority of the respondents were male (60%), between 15 and 17 years (45%), Christian (93%) and in their first year of study. The adolescents had basic knowledge, positive attitude, and poor practices towards HBV. There was no significant relationship between the demographic variables of the respondents and KAP mean scores.

CONCLUSION

There is the need to introduce health education and awareness programs in schools within the Asante Mampong Municipality to improve students' level of knowledge of HBV. Countrywide studies examining KAP towards HBV infection among adolescents are also warranted.

Physician network connections to specialists and HIV quality of care

OBJECTIVE

To estimate novel measures of generalist physicians' network connectedness to HIV specialists and their associations with two dimensions of HIV quality of care.

DATA SOURCES

Medicare and Medicaid claims and the American Medical Association Masterfile data on people living with HIV (PLWH) and the physicians providing their HIV care in California between 2007 and 2010.

STUDY DESIGN

I construct regional patient-sharing physician networks from the shared treatment of PLWH and calculate (a) measures of network connectedness to all physician types and (b) specialty-weighted measures to describe connectedness to HIV specialists. Two HIV quality of care outcomes are then evaluated: medication quality (prescribing antiretroviral drugs from at least two drug classes) and monitoring quality (at least two annual HIV virus monitoring scans). Linear probability models estimate the associations between network statistics and the two dimensions of HIV quality of care, and a policy simulation demonstrates the importance of these statistical relationships. These analyses include 16 124 PLWH, 3240 generalists, and 1031 HIV specialists.

DATA COLLECTION/EXTRACTION METHODS

PLWH are identified from claims for patients with any indication of HIV using an existing algorithm from the literature.

PRINCIPAL FINDINGS

Generalists' network connectedness to HIV specialists is positively related with their own HIV medication quality; one additional HIV specialist connection is associated with a 1.46 percentage point (SE 0.42, P < .01) increase in generalist's medication quality. Based on the estimated associations, a simulated policy that increases connectedness between generalists and HIV specialists reduces the annual rate of HIV infections by up to 6%, roughly 290 fewer infections per year. Only network connectedness to all physician types is associated with improved monitoring quality.

CONCLUSIONS

Network connectedness to HIV specialists is positively associated with generalists' HIV medication quality, which suggests that specialists provide clinical support through patient-sharing for complex treatment protocol.

Trabecular bone scores in young HIV-infected men: a matched case-control study

Background

Screening for osteoporosis with dual-energy X-ray absorptiometry (DXA) is recommended for male HIV-infected patients only above the age of 50. Recently, trabecular bone score (TBS) has been introduced as a novel tool to assess bone microarchitecture using DXA of the lumbar spine. Few studies have reported TBS values in HIV-infected individuals younger than 50 years of age. This study compared TBS values in young males infected with HIV and matched controls, and investigated the associations between TBS and demographic parameters, clinical parameters, and bone mineral density (BMD) scores.

Methods

A cross-sectional study of BMD and TBS in HIV-infected men (n = 80) aged between 18 and 50 years and age- and sex-matched controls (n = 80) was conducted.

Results

The proportion of patients with low BMD (Z-score ≤ − 2) was significantly greater among HIV-infected patients than among matched controls (21.3% [17/80] vs. 8.8% [7/80], p = 0.027). Mean TBS values were significantly lower in HIV-infected patients than in controls (1.41 ± 0.07 vs. 1.45 ± 0.07, p = 0.008). In both groups, TBS values were positively correlated with BMD at the lumbar spine, femoral neck, and total hip (p < 0.001); however, TBS was not correlated with body mass index. In the HIV group, TBS was negatively correlated with the duration of tenofovir disoproxil fumarate(TDF) exposure (p = 0.04).

Conclusion

Young men infected with HIV had abnormal bone trabecular microarchitecture, as assessed by both TBS and BMD. TBS values were correlated with both BMD and the duration of TDF exposure.

Decreased ratio of influenza-specific IgG versus IgM in response to influenza vaccination in antiretroviral-treated HIV-infected African Americans compared to Caucasians, and its direct correlation with the percentages of peripheral Tfh cells

BACKGROUND

Racial differences have been observed in the rate of bacterial infection and disease progression in HIV. Here, we evaluate racial differences in seasonal influenza vaccine responses.

METHODS

16 healthy controls (9 Caucasians (CC) and 7 African Americans (AA)) and 26 antiretroviral therapy (ART)-treated aviremic HIV+ subjects (11 CC and 15 AA) were enrolled in the current study. Blood was collected at pre-vaccination (D0) and day 14 (D14) following seasonal influenza vaccination. Serologic responses were characterized in plasma by ELISA. B and T cells were assessed by flow cytometry ex vivo.

RESULTS

The absolute counts of CD4+ CD3+ T cells and CD19+ B cells were similar in healthy controls and HIV-infected individuals, and similar in CC and AA in the two study groups. However, the percentage of peripheral T follicular helper (pTfh) cells was decreased in HIV+ AA compared to HIV+ CC. There were no racial differences in IgG antibody responses against vaccination in the two study groups. However, the ratio of anti-influenza-specific IgG versus IgM induction following vaccination was decreased in HIV+ AA compared to HIV+ CC, which was directly correlated with the percentages of pTfh cells. This racial difference and correlation were not demonstrable in healthy controls.

CONCLUSION

Here we report that HIV + AA has decreased fold induction of IgG versus IgM after influenza vaccination, which may suggest impaired class-switching from IgM to IgG in AA HIV-infected individuals.

Facilitators of and barriers to high-resolution anoscopy adherence among men who have sex with men: a qualitative study

Background Anal cancer is a rare malignancy that disproportionately affects men who have sex with men (MSM) and HIV-infected people. Anal cancer is associated with human papillomavirus (HPV) in upward of 90% of cases and is preceded by pre-cancerous changes in cells of the anal canal. High-resolution anoscopy (HRA) is used for the detection, treatment and continued monitoring of anal dysplasia. Practice guidelines regarding anal cancer prevention vary by jurisdiction and institution, and patient engagement is low for high-risk populations such as MSM. The purpose of this study is to characterise perceptions among MSM of barriers to and facilitators of their adherence to HRA follow-up recommendations.

METHODS

Surveys and in-person focus groups with MSM who were either adherent or non-adherent to HRA follow-up recommendations at a Federally Qualified Health Centre in Boston, MA, which specialises in sexual and gender minority care, were conducted. Facilitators of and barriers to follow-up were identified by deductive content analysis.

RESULTS

Focus group participants identified the following barriers to and facilitators of HRA follow up: (1) patient-level beliefs about HPV-related disease or HRA, ability to engage in care, internalised stigma and physical discomfort; (2) provider-level knowledge and expertise, communication skills and relationship-building with patient; and (3) systems-level societal stigma and healthcare system inefficiencies.

CONCLUSIONS

Reinforcing facilitators of and reducing barriers to HRA follow up may improve adherence among MSM. This includes improvements to: patient education, provider training to increase knowledge and cultural sensitivity, public awareness about HPV-related anal cancer, physical discomfort associated with HRA and systems inefficiencies.

Increased influenza-specific antibody avidity in HIV-infected women compared with HIV-infected men on antiretroviral therapy

BACKGROUND

It is recommended that HIV-infected individuals receive annual influenza vaccination due to their high susceptibility to influenza infection, especially among women. However, there have been few studies investigating sex-related responses to influenza vaccine in antiretroviral therapy (ART)-treated HIV-infected individuals.

METHOD

In this study, 26 aviremic ART-treated HIV-infected individuals and 16 healthy controls were enrolled in the current study. Blood was collected prior to vaccination (D0), on days 7-10 (D7) and on days 14-21 (D14) following administration of the 2013-2014 seasonal influenza vaccine. A series of analyses evaluated the serological and cellular responses following influenza vaccination.

RESULTS

Female HIV-infected individuals had increased influenza-specific antibody avidity relative to male HIV-infected individuals, but similar plasma levels of influenza-specific binding antibodies and neutralizing antibodies. Increased cycling B cells and follicular helper CD4 T (Tfh) cells were observed in female HIV-infected individuals pre and postvaccination compared with male HIV-infected individuals, and cycling Tfh cells were directly correlated with influenza-specific antibody avidity. Moreover, plasma testosterone levels were inversely correlated with antibody avidity index. The magnitude of microbial translocation [plasma lipopolysaccharide (LPS)] level was directly correlated with influenza-specific antibody avidity. Circulating 16S rDNA microbiome showed that enrichment of specific species within Proteobacteria was associated with influenza-specific antibody avidity. These results, including differences based on sex and correlations, were only observed in HIV-infected individuals but not in the healthy controls.

CONCLUSION

This study demonstrated sex differences in influenza-specific antibody avidity in ART-treated HIV disease, and provides valuable information on vaccination strategy in the ART-treated HIV-infected population.

Cessation-related information, motivation, and behavioral skills in smokers living with HIV

There is a need for new, targeted smoking cessation interventions for smokers living with HIV. The Information-Motivation-Behavioral Skills (IMB) model has been applied effectively to HIV-related health behaviors and was used in this qualitative study to elicit factors that could lead to the development of innovative and successful cessation interventions for this population. Twenty individuals who smoked from two clinics providing care to people living with HIV participated in open-ended interviews, responding to questions covering the domains of the IMB model, as applied to smokers living with HIV. Participants were enrolled from a larger survey cohort to recruit into groups based on the impact of HIV diagnosis on smoking as well as attempting to enroll a mix of demographics characteristics. Interviews were recorded, transcribed, coded and thematically analyzed using a grounded theory qualitative approach. Interviews continued until thematic saturation was reached. Major themes included: Presence of knowledge deficits regarding HIV-specific health risks of smoking; use of smoking for emotional regulation, where many reported close contacts who smoke and concern with the effect of cessation on their social networks; Use of smoking cessation aids or a telephone-based wellness intervention were acceptable to most. Providing HIV-specific information in cessation advice is of the utmost importance for clinicians caring for smokers living with HIV, as this theme was noted consistently as a potential motivator to quit. Innovative and effective interventions must account for the social aspect of smoking and address other methods of emotional regulation in this population.

"Tweak Your Order Set!" Implementation of Modified Laboratory Order Set Improves Hepatitis C Virus Screening Rates in People Living With Human Immunodeficiency Virus

There are several barriers to annual hepatitis C virus antibody (HCVAb) testing, including lack of provider knowledge of the changing HCV epidemic and provider underestimation of a patient’s risk. We identified low rates of testing for HCVAb in people living with human immunodeficiency virus (HIV) in our outpatient HIV Infectious Diseases clinic, and we developed a quality improvement project to increase rates of HCVAb screening.

Retention, Antiretroviral Therapy Use and Viral Suppression by History of Injection Drug Use Among HIV-Infected Patients in an Urban HIV Clinical Cohort

Compared to HIV-infected persons who do not inject drugs (non-IDU), persons who inject drugs (PWID) experience disparities in linking to medical care, initiating antiretroviral therapy (ART) and achieving viral suppression. There has been little attention to changes in these disparities over time. We estimated the proportion of PWID and non-IDU retained in care, on ART, and virally suppressed each year from 2001-2012 in the Johns Hopkins HIV Clinical Cohort (JHHCC). We defined active clinic patients as those who had ≥1 clinical visit, CD4 cell count, or viral load between July 1 of the prior year, and June 30 of the analysis year. Within a calendar year, retention was defined as ≥2 clinical visits or HIV-related laboratory measurements >90 days; ART use was defined as ≥1 ART prescription active ≥30 days; and viral suppression was defined as ≥1 HIV viral load <400 copies/mL. While PWID were less likely to be retained in earlier years, the gaps in retention closed around 2010. After 2003-2004, PWID and non-IDU retained in care had similar probability of receiving a prescription for ART and PWID and non-IDU on ART had similar probability of viral suppression.

Increased Sexually Transmitted Disease Testing Among Sexually Active Persons Receiving Medical Care for Human Immunodeficiency Virus Infection in the United States, 2009-2013

Background

Current guidelines recommend that all sexually active human immunodeficiency virus (HIV)-infected persons be tested at least annually for syphilis, chlamydia, and gonorrhea. We examined temporal trends in syphilis, chlamydia, and gonorrhea testing among sexually active HIV-infected adults receiving medical care in the United States during 2009-2013.

Methods

Using medical record data from the Medical Monitoring Project, a population-based HIV surveillance system, we assessed the proportion of adults receiving HIV medical care who were tested for syphilis, chlamydia, and gonorrhea in the past 12 months by year and stratified by sex and sexual behavior, age, and race/ethnicity.

Results

During 2009-2013, the proportion of sexually active HIV-infected adults receiving medical care who were tested in the past year for all 3 examined sexually transmitted diseases (STDs) increased from 20% to 36% (PTREND < .01). Overall testing for syphilis increased from 55% to 65% (PTREND < .01), and significant increases were noted for the following subgroups: men who have sex with men (58% to 69%), non-Hispanic whites (48% to 64%), and all age groups with the exception of persons aged 18-29 year. Overall testing for chlamydia and gonorrhea increased from 22% to 42% (PTREND < .01), and significant increases were noted for most subgroups.

Conclusions

STD testing significantly increased among sexually active HIV-infected adults receiving medical care; however, the majority of persons were not tested for all 3 STDs in 2013. While increased testing indicates progress, testing remained far below recommended guidelines. Our findings suggest enhanced efforts may be warranted to screen all sexually active HIV-infected adults for syphilis, chlamydia, and gonorrhea.

Reducing non-injection drug use in HIV primary care: A randomized trial of brief motivational interviewing, with and without HealthCall, a technology-based enhancement

AIMS

In HIV-infected individuals, non-injection drug use (NIDU) compromises many health outcomes. In HIV primary care, the efficacy of brief motivational interviewing (MI) to reduce NIDU is unknown, and drug users may need greater intervention. We designed an enhancement to MI, HealthCall (HC), for daily patient self-monitoring calls to an interactive voice response (IVR) phone system, and provided participants with periodic personalized feedback. To reduce NIDU among HIV primary care patients, we compared the efficacy of MI+HealthCall to MI-only and an educational control condition.

DESIGN

Participants age >18 with >4days of NIDU during the prior 30days were recruited from large urban HIV primary care clinics. Of the 240 participants, 83 were randomly assigned to control, 77 to MI-only, and 80 to MI+HC. Counselors provided educational control, MI-only or MI+HC at baseline. At 30 and 60days (end-of-treatment), counselors briefly discussed drug use, moods and health behaviors, using HealthCall-generated graphs with MI+HC patients. Primary outcomes (last 30days) were number of days used primary drug (NumDU), and total quantity of primary drug used (dollar amount spent; QuantU), derived from the Time-Line Follow-Back.

FINDINGS

Across all groups, at end-of-treatment, frequency and quantity of NIDU decreased, with significantly greater reductions in the MI-Only group. A twelve-month post-treatment follow-up indicated sustained benefits of MI+HC and MI-only relative to control.

CONCLUSIONS

Brief interventions can be successfully used to reduce non-injection drug use in HIV primary care. IVR-based technology may not be sufficiently engaging to be effective. Future studies should investigate mobile technology to deliver a more engaging version of HealthCall to diverse substance abusing populations.

The induction of CD80 and apoptosis on B cells and CD40L in CD4+ T cells in response to seasonal influenza vaccination distinguishes responders versus non-responders in healthy controls and aviremic ART-treated HIV-infected individuals

BACKGROUND

Studies have shown that HIV infection is associated with an impaired influenza vaccine response. We examined the role of cellular phenotypes and function in influenza vaccine responsiveness in healthy controls and aviremic HIV-infected subjects on antiretroviral treatment (ART).

METHODS

16 healthy controls and 26 ART+ aviremic HIV+ subjects were enrolled in the current study. Blood was collected at pre-vaccination (D0), and on days 7-10 (D7) and 14-21 (D14) following the 2013-2014 seasonal influenza vaccine administrations. Subjects were classified as responders if neutralizing titers against H1N1 virus increased ⩾4-fold at D14 compared to D0. A serial analysis of B and CD4+ T cell frequencies and activation was performed on D0 and D7 by flow cytometry.

RESULTS

9 of 26 (34.6%) HIV-infected individuals and 7 of 16 (43.8%) healthy controls were classified as responders to influenza vaccines. Total B cell apoptosis (annexin V) was increased on D7 post-vaccination in non-responders but not in responders among both controls and HIV+ subjects. Surface CD80 expression on memory B cells and intracellular CD40L expression on memory CD4+ T cells were induced on D7 in responders of controls but not in non-responders. The CD80 and CD40L induction was not demonstrable in HIV-infected subjects regardless of responders and non-responders. Memory CD4+ T cell cycling tended to increase on D7 in the four study groups but did not achieve significance. All the other parameters were indistinguishable between responders and non-responders, regardless of HIV-infection status.

CONCLUSION

The perturbation of activation and apoptotic induction on B cells or CD4+ T cells after seasonal influenza vaccination in non-responders and HIV-infected subjects may help understand the mechanism of impaired vaccine responsiveness.

Associations and Trends in Cause-Specific Rates of Death Among Persons Reported with HIV Infection, 23 U.S. Jurisdictions, Through 2011

Background:

Published death rates for persons with HIV have not distinguished deaths due to HIV from deaths due to other causes. Cause-specific death rates would allow better assessment of care needs.

Methods:

Using data reported to the US national HIV surveillance system, we examined a) associations between selected decedent characteristics and causes of death during 2007-2011, b) trends in rates of death due to underlying causes among persons with AIDS during 1990-2011, and among all persons with diagnosed HIV infection (with or without AIDS) during 2000-2011.

Results:

During 2007-2011, non-HIV-attributable causes of death with the highest rates per 1,000 person-years were heart disease (2.0), non-AIDS cancers other than lung cancer (1.4), and accidents (0.8). During 1990-2011, among persons with AIDS, the annual rate of death due to HIV-attributable causes decreased by 89% (from 122.0 to 13.2), and the rate due to non-HIV-attributable-causes decreased by 57% (from 20.0 to 8.6), while the percentage of deaths caused by non-HIV-attributable causes increased from 11% to 43%. During 2000-2011, among persons with HIV infection, the rate of death due to HIV-attributable causes decreased by 69% (from 26.4 to 8.3), and the rate due to non-HIV-attributable causes decreased by 28% (from 10.5 to 7.6), while the percentage of deaths caused by non-HIV-attributable causes increased from 25% to 48%.

Conclusion:

Among HIV-infected persons, as rates of death due to HIV-attributable causes decreased, rates due to non-HIV-attributable causes also decreased, but the percentages of deaths due to non-HIV-attributable causes, such as heart disease and non-AIDS cancers increased.

Drug-Drug Interactions and HIV Therapy: What Should Pharmacists Know?

Drug-interaction issues continue to present a major dilemma for the clinician caring for complex patients such as those infected with HIV. The inherent possibility of a drug interaction is magnified by the multitude of drugs being administered in highly-active antiretroviral therapy (HAART). In addition, other classes of medications are used to alleviate side effects, reduce toxicities associated with HAART, or treat concomitant diseases. The modification of one drug by another substance or drug-drug interaction is the main focus of this article. Drug-drug interactions may result in toxicity, treatment failure, or loss of effectiveness and can significantly affect a patient’s clinical outcome. An understanding of the fundamental mechanisms of HIV drug-drug interactions may allow for the early detection or avoidance of troublesome regimens and prudent management if they develop. Although HIV drug interactions are usually thought of as detrimental, resulting in a loss of therapeutic effect or toxicity, some drug interactions such as ritonavir boosted protease inhibitor–based antiretroviral treatments are beneficial and are commonly used in clinical practice. Therefore, pharmacists need to understand drug interaction mechanisms, remember key drug interactions, and vigilantly monitor patients for potential complications.

Adverse Effects Associated With Antiretroviral Therapy and Potential Management Strategies

A variety of adverse drug reactions (ADRs) affecting many organ systems may be observed with antiretroviral therapy (ARV), and they can be differentiated into short- and long- term effects, class effects, or individual drug effects. Commonly seen ADRs include dermatological reactions, associated with nonnucleoside reverse transcriptase inhibitors (NNRTIs) and some protease inhibitors (PIs), and gastrointestinal problems, a major side effect of PIs and of some nucleoside reverse transcriptase inhibitors (NRTIs). Metabolic complications are frequently reported in HIV-infected patients on ARV and often coexist. Lipodystrophy, hyperinsulinemia/hyperglycemia, and bone disorders (osteoporosis, osteonecrosis) are mainly associated with PIs, while lactic acidemia/acidosis are primarily a problem of NRTIs. Hyperlipidemia may be caused by almost all PIs, few NRTIs, and NNRTIs. All antiretroviral drug classes may cause both asymptomatic and symptomatic hepatotoxicity, although nevirapine is the agent most implicated in hepatic events. More drug-specific ADRs include nephrotoxicity (indinavir and tenofovir), central nervous system problems (efavirenz), hematological disturbances (zidovudine), and hypersensitivity reactions (abacavir). Anticipation of ADRs may influence a patient’s decision to delay ARV or to choose specific and potentially less active agents. Occurrence of ADRs may significantly impact a patient’s quality of life and drug adherence. Pharmacists counseling HIV-infected patients should be aware of common ADRs with ARV and potential management strategies.

Hepatitis C Screening in People With Human Immunodeficiency Virus: Lessons Learned From Syphilis Screening

Background.  The incidence of hepatitis C virus (HCV) infection is increasing in human immunodeficiency virus (HIV)-positive men who have sex with men (MSM). New guidelines recommend annual screening for HCV, similar to recommendations for syphilis screening with rapid plasma reagin (RPR). Methods.  This study compares the frequency of repeat HCV antibody (Ab) testing to repeat RPR testing in a retrospective chart review of 359 HCVAb-negative people living with HIV (PLWH) observed in an Infectious Diseases clinic. Patients were classified into risk groups based on sexual risk factors. Results.  Although 85% of PLWH had repeat syphilis screening, less than two thirds had repeat HCVAb screening. The MSM status was associated with increased HCVAb and RPR testing (adjusted odds ratio, 2.6 and 5.9, respectively). Seven persons had incident HCV infection: 3 were MSM, and 4 had symptoms or abnormal laboratory results to prompt testing. Conclusions.  Failure to find incident HCV infection in PLWH represents missed opportunities to cure HCV infection and prevent progressive liver disease. Further quality improvement studies are necessary to develop physician-focused interventions to increase HCV screening rates in PLWH.

Key differences in B cell activation patterns and immune correlates among treated HIV-infected patients versus healthy controls following influenza vaccination

BACKGROUND

There is increasing recognition of the role of B cell dysfunction in HIV pathogenesis, but little is known about how these perturbations may influence responses to vaccinations.

METHODS

Healthy controls (n=16) and antiretroviral therapy (ART)-treated aviremic HIV-infected subjects (n=26) receiving standard-of-care annual influenza vaccinations were enrolled in the present study. Total bacterial 16S rDNA levels were assessed by quantitative polymerase chain reactions in plasma. Serologic responses were characterized by ELISA, hemagglutination inhibition assay (HI), and microneutralization, and cell-mediated responses were assessed by ELISPOT (antigen-specific IgG+ antibody-secreting cells (ASCs)) and flow cytometry at pre-vaccination (D0), day 7-10 (D7) and day 14-21 (D14) post-vaccination.

RESULTS

Decreased peripheral CD4+ T cell absolute counts and increased frequencies of cycling and apoptotic B cells were found at baseline in HIV-infected subjects relative to healthy controls. In healthy controls, post-vaccination neutralizing activities were related to the frequencies of vaccine-mediated apoptosis and cycling of B cells, but not to CD4+ T cell counts. In patients, both baseline and post-vaccination neutralizing activities were directly correlated with plasma level of bacterial 16S rDNA. However, overall vaccine responses including antibody titers and fold changes were comparable or greater in HIV-infected subjects relative to healthy controls.

CONCLUSION

B cell function correlates with measures of recall humoral immunity in response to seasonal influenza vaccination in healthy controls but not in ART-treated patients.

Mental Health and Substance Use Among Patients in a North Carolina HIV Clinic

BACKGROUND

The HIV/AIDS epidemic is a significant public health concern in North Carolina, and previous research has pointed to elevated mental health distress and substance use among HIV-infected populations, which may impact patients' adherence to medications. The aims of this study were to describe the prevalence of mental health and substance use issues among patients of a North Carolina HIV clinic, to examine differences by demographic characteristics, and to examine factors associated with suboptimal adherence to HIV medications.

METHODS

This study was a secondary analysis of clinical data routinely collected through a health behavior questionnaire at a large HIV clinic in North Carolina. We analyzed data collected from February 2011 to August 2012.

RESULTS

The sample included 1,398 patients. Overall, 12.2% of patients endorsed current symptomology indicative of moderate or severe levels of depression, and 38.6% reported receiving a psychiatric diagnosis at some point in their life. Additionally, 19.1% had indications of current problematic drinking, and 8.2% reported problematic drug use. Nearly one-quarter (22.1%) reported suboptimal adherence to HIV medications. Factors associated with poor adherence included racial/ethnic minority, age less than 35 years, and indications of moderate or severe depression.

LIMITATIONS

The questionnaire was not completed systematically in the clinic, which may limit generalizability, and self-reported measures may have introduced social desirability bias.

CONCLUSION

Patients were willing to disclose mental health distress, substance use, and suboptimal medication adherence to providers, which highlights the importance of routinely assessing these behaviors during clinic visits. Our findings suggest that treating depression may be an effective strategy to improve adherence to HIV medications.

Brief Report: Gonorrhea and Chlamydia Testing Increasing but Still Lagging in HIV Clinics in the United States

Screening persons living with HIV for gonorrhea and chlamydia has been recommended since 2003. We compared annual gonorrhea/chlamydia testing to syphilis and lipid testing among 19,368 adults (41% men who have sex with men, 30% heterosexual men, and 29% women) engaged in HIV care. In 2004, 22%, 62%, and 70% of all patients were tested for gonorrhea/chlamydia, syphilis, and lipid levels, respectively. Despite increasing steadily [odds ratio per year (95% confidence interval): 1.14 (1.13 to 1.15)], gonorrhea/chlamydia testing in 2010 remained lower than syphilis and lipid testing (39%, 77%, 76%, respectively). Interventions to improve gonorrhea/chlamydia screening are needed. A more targeted screening approach may be warranted.

Cholesterol Levels in HIV- and/or HCV-Infected Drug Users Living in Argentina

Improved understanding of cholesterol levels in HIV- and hepatitis C virus (HCV)-infected persons in Argentina will guide optimal antiretroviral therapy. The authors conducted a cross-sectional study in Argentina to describe associations between HIV, HCV, and cholesterol. Of the 202 participants, 21 were HIV infected, 15 were HCV infected, 46 were HIV/HCV coinfected, and 120 were HIV/HCV uninfected. HIV/HCV-uninfected participants had the highest total cholesterol (TC) and low-density lipoprotein (LDL) levels. Multivariate modeling revealed that HIV/HCV-coinfected patients had the lowest TC levels (-28.7 mg/dL, P < .001) compared to the HIV/HCV-uninfected reference group. Hepatitis C virus and HIV/HCV coinfection were associated with lower LDL levels (-21.4 mg/dL, P = .001 and -20.3 mg/dL, P < .0001, respectively). HIV and HIV/HCV coinfection, but not HCV alone, were associated with lower high-density lipoprotein levels (-9.1 mg/dL, P = .0008 and -6.8 mg/dL, P = .0006, respectively). Further study is needed to examine whether the more favorable lipid profile observed in HIV/HCV-coinfected persons is associated with a reduction in cardiovascular risk.

Bacterial sexually transmitted infections among HIV-infected patients in the United States: estimates from the Medical Monitoring Project

BACKGROUND

Bacterial sexually transmitted infections may facilitate HIV transmission. Bacterial sexually transmitted infection testing is recommended for sexually active HIV-infected patients annually and more frequently for those at elevated sexual risk. We estimated percentages of HIV-infected patients in the United States receiving at least one syphilis, gonorrhea, or chlamydia test, and repeat (≥2 tests, ≥3 months apart) tests for any of these sexually transmitted infections from mid-2008 through mid-2010.

DESIGN

The Medical Monitoring Project collects behavioral and clinical characteristics of HIV-infected adults receiving medical care in the United States using nationally representative sampling.

METHODS

Sexual activity included self-reported oral, vaginal, or anal sex in the past 12 months. Participants reporting more than 1 sexual partner or illicit drug use before/during sex in the past year were classified as having elevated sexual risk. Among participants with only 1 sex partner and no drug use before/during sex, those reporting consistent condom use were classified as low risk; those reporting sex without a condom (or for whom this was unknown) were classified as at elevated sexual risk only if they considered their sex partner to be a casual partner, or if their partner was HIV-negative or partner HIV status was unknown. Bacterial sexually transmitted infection testing was ascertained through medical record abstraction.

RESULTS

Among sexually active patients, 55% were tested at least once in 12 months for syphilis, whereas 23% and 24% received at least one gonorrhea and chlamydia test, respectively. Syphilis testing did not vary by sex/sexual orientation. Receipt of at least 3 CD4+ T-lymphocyte cell counts and/or HIV viral load tests in 12 months was associated with syphilis testing in men who have sex with men (MSM), men who have sex with women only, and women. Chlamydia testing was significantly higher in sexually active women (30%) compared with men who have sex with women only (19%), but not compared with MSM (22%). Forty-six percent of MSM were at elevated sexual risk; 26% of these MSM received repeat syphilis testing, whereas repeat testing for gonorrhea and chlamydia was only 7% for each infection.

CONCLUSIONS

Bacterial sexually transmitted infection testing among sexually active HIV-infected patients was low, particularly for those at elevated sexual risk. Patient encounters in which CD4+ T-lymphocyte cell counts and/or HIV viral load testing occurs present opportunities for increased bacterial sexually transmitted infection testing.

Depression and human immunodeficiency virus infection are risk factors for incident heart failure among veterans: Veterans Aging Cohort Study

BACKGROUND

Both HIV and depression are associated with increased heart failure (HF) risk. Depression, a common comorbidity, may further increase the risk of HF among adults with HIV infection (HIV+). We assessed the association between HIV, depression, and incident HF.

METHODS AND RESULTS

Veterans Aging Cohort Study (VACS) participants free from cardiovascular disease at baseline (n=81 427: 26 908 HIV+, 54 519 without HIV [HIV-]) were categorized into 4 groups: HIV- without major depressive disorder (MDD) [reference], HIV- with MDD, HIV+ without MDD, and HIV+ with MDD. International Classification of Diseases, Ninth Revision codes from medical records were used to determine MDD and the primary outcome, HF. After 5.8 years of follow-up, HF rates per 1000 person-years were highest among HIV+ participants with MDD (9.32; 95% confidence interval [CI], 8.20-10.6). In Cox proportional hazards models, HIV+ participants with MDD had a significantly higher risk of HF (adjusted hazard ratio, 1.68; 95% CI, 1.45-1.95) compared with HIV- participants without MDD. MDD was associated with HF in separate fully adjusted models for HIV- and HIV+ participants (adjusted hazard ratio, 1.21; 95% CI, 1.06-1.37; and adjusted hazard ratio, 1.29; 95% CI, 1.11-1.51, respectively). Among those with MDD, baseline antidepressant use was associated with lower risk of incident HF events (adjusted hazard ratio, 0.76; 95% CI, 0.58-0.99).

CONCLUSIONS

Our study is the first to suggest that MDD is an independent risk factor for HF in HIV+ adults. These results reinforce the importance of identifying and managing MDD among HIV+ patients. Future studies must clarify mechanisms linking HIV, MDD, antidepressants, and HF and identify interventions to reduce HF morbidity and mortality in those with both HIV and MDD.

Short Communication: Viral Suppression Is Associated with Increased Likelihood of Colorectal Cancer Screening Among Persons Living with HIV/AIDS

With improved survival and aging, more persons living with HIV/AIDS (PLWHA) are at risk for colorectal cancer (CRC). This retrospective longitudinal study evaluated patient characteristics associated with CRC screening in our HIV cohort. Patients were followed beginning at age 50 years during a study period from January 1, 2003 to December 31, 2010 (n=265). During a median follow-up time of 1.7 years, only 30% of patients underwent CRC screening. The majority of screened patients received endoscopic screening (colonoscopy, 86%; sigmoidoscopy, 8%); among these patients, results were available for 68/75, and adenomatous polyps were found in 13%. No cases of CRC were reported. Among unscreened patients, only 23% had an external primary care provider, indicating an HIV provider was the expected source for CRC screening referral in the majority. Patients with time-varying suppressed HIV viral load were more likely to receive screening (HRadjusted=1.74; 95% CI: 1.05-2.87), independent of CD4 count. Our findings suggest HIV providers are more likely to address non-HIV-related healthcare maintenance when HIV is controlled. In addition, a significant number of neoplastic lesions are likely being missed in PLWHA who have not been screened for CRC. Provision of evidence-based preventive care in addition to HIV care is required for the aging population of PLWHA.

Care of the HIV-infected pregnant woman in the developed world

The reduction of human immunodeficiency virus (HIV) transmission from mother to child is one of the success stories of modern medicine and public health. In the developed world, with universal HIV counseling and testing, antiretroviral prophylaxis, scheduled Caesarean delivery if indicated, and avoidance of breastfeeding, HIV transmission from mother to infant can be <2%. Despite this, transmissions continue to occur, often due to lack of knowledge of HIV status. Missed opportunities for prevention and prevention challenges include late prenatal care, lack of HIV testing in pregnancy, lack of preconception counseling, unintended pregnancy, and substance abuse. We review preconception counseling including options for serodiscordant couples, and antepartum, peripartum and postpartum care of the HIV-infected woman in the developed world, and advocate for a comprehensive, collaborative, multidisciplinary approach.

Tuberculosis and HIV Coinfection

Tuberculosis (TB) and human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) constitute the main burden of infectious disease in resource-limited countries. In the individual host, the two pathogens, Mycobacterium tuberculosis and HIV, potentiate one another, accelerating the deterioration of immunological functions. In high-burden settings, HIV coinfection is the most important risk factor for developing active TB, which increases the susceptibility to primary infection or reinfection and also the risk of TB reactivation for patients with latent TB. M. tuberculosis infection also has a negative impact on the immune response to HIV, accelerating the progression from HIV infection to AIDS. The clinical management of HIV-associated TB includes the integration of effective anti-TB treatment, use of concurrent antiretroviral therapy (ART), prevention of HIV-related comorbidities, management of drug cytotoxicity, and prevention/treatment of immune reconstitution inflammatory syndrome (IRIS).

Seroprotection of HIV-infected subjects after influenza A(H1N1) vaccination is directly associated with baseline frequency of naive T cells

Human immunodeficiency virus type 1 (HIV-1)-infected individuals, despite receipt of antiretroviral therapy (ART), often have impaired vaccine responses. We examined the role that immune activation and cellular phenotypes play in influenza A(H1N1) vaccine responsiveness in HIV-infected subjects receiving ART. Subjects received the H1N1 vaccine (15-µg dose; Novartis), and antibody titers at baseline and after immunization were evaluated. Subjects were classified as responders if, by week 3, seroprotection guidelines were met. Responders had higher percentages of baseline naive T cells and lower percentages of terminally differentiated T cells, compared with nonresponders. Additionally, the naive CD4(+) T-cell percentage and age were negatively correlated. Preservation of naive T-cell populations by starting therapy early could impact vaccine responses against influenza virus and other pathogens, especially as this population ages.

Predictive factors for loss to postpartum follow-up among low income HIV-infected women in Texas

Guidelines for HIV primary care include visits every 3 months (up to 6 months in those with stable HIV). During pregnancy, women with HIV commonly attend once weekly to once monthly visits; however, after delivery, many are lost to follow-up. Our goal was to assess the frequency of loss to primary care follow-up postpartum and to identify predictors of loss to care. A retrospective chart review of HIV-infected women in a Houston prenatal program was done. Optimal care was defined as one visit to HIV primary care providers (PCPs) every 6 months within the first year after delivery, and loss to follow-up as no visits within the first postpartum year. Multivariate logistic regression analysis was used to identify factors associated with loss to follow-up. Charts (n=213) were analyzed for follow-up with PCPs. The loss to follow-up rate was 39% in the first postpartum year. Associated factors were younger age, black race, late entry to prenatal care, and no plans for contraception. Predictors of loss to primary care after pregnancy can be used to identify specific subpopulations of pregnant women at highest risk for falling out of care.

Tobacco use among HIV-infected individuals in a rural community in Yunnan Province, China

OBJECTIVE

To examine the prevalence and correlates of smoking versus tobacco chewing, and potential gender differences in tobacco use among HIV-infected individuals in a rural community in Yunnan Province, China.

METHOD

A cross-sectional design using face-to-face interviews.

RESULTS

Among the participants, 301 (66.2%) were male; 79 (17.4%) were ethnic Han, 310 (68.1%) were Jingpo minority, 62 (13.6%) were Dai minority; 17.8% had no formal education and 55.6% had only primary school education; 15.4% were never married; 40% reported drinking in the past 30 days; 55.4% had ever used drugs; and 67% were currently receiving antiretroviral therapy (ART). The mean age of the study participants was 38.1 years (SD=8.8). About 62% were current cigarette smokers. Current cigarette smoking was positively associated with being male (OR=142.43, 95% CI: 35.61-569.72) and current drinking (OR=7.64, 95% CI: 2.68-21.81), as well as having ever used drugs (OR=4.03, 95% CI: 1.31-12.35). Among current smokers, 67.6% were heavy smokers (smoked at least 20 cigarettes per day). Those who were older than 46 years of age (OR=9.68, 95% CI: 1.41-66.59) and current drinkers (OR=2.75, 95% CI: 1.56-4.83) were more likely to be heavy smokers. Approximately 9% were currently used chewing tobacco. Those who were female (OR=41.29, 95% CI: 8.53-199.93) and current drinkers (OR=3.22, 95% CI: 1.02-10.16) were more likely to use chewing tobacco. All who used chewing tobacco were ethnic minorities.

CONCLUSIONS

Cigarette smoking and use of chewing tobacco were highly prevalent among HIV-infected individuals in rural Yunnan, underscoring the urgent need for tobacco prevention and intervention programs tailored for this population.

A randomized controlled trial examining the efficacy of motivational counseling with observed therapy for antiretroviral therapy adherence

This study determined whether motivational interviewing-based cognitive behavioral therapy (MI-CBT) adherence counseling combined with modified directly observed therapy (MI-CBT/mDOT) is more effective than MI-CBT counseling alone or standard care (SC) in increasing adherence over time. A three-armed randomized controlled 48-week trial with continuous electronic drug monitored adherence was conducted by randomly assigning 204 HIV-positive participants to either 10 sessions of MI-CBT counseling with mDOT for 24 weeks, 10 sessions of MI-CBT counseling alone, or SC. Poisson mixed effects regression models revealed significant interaction effects of intervention over time on non-adherence defined as percent of doses not-taken (IRR = 1.011, CI = 1.000–1.018) and percent of doses not-taken on time (IRR = 1.006, CI = 1.001–1.011) in the 30 days preceding each assessment. There were no significant differences between groups, but trends were observed for the MI-CBT/mDOT group to have greater 12 week on-time and worse 48 week adherence than the SC group. Findings of modest to null impact on adherence despite intensive interventions highlights the need for more effective interventions to maintain high adherence over time.

Acute human immunodeficiency virus infection

The clinical spectrum of acute human immunodeficiency virus (HIV) infection, a common clinical syndrome, may range from asymptomatic to a severe illness. The purpose of this review is to increase awareness of this syndrome, which is rarely suspected and often missed in clinical care settings, and provide an informative reference for primary care providers. The diagnosis of acute HIV infection is important for both patient care and public health concerns. In this article, the epidemiology, pathophysiology, clinical presentation, diagnosis and treatment of acute HIV infection are reviewed.

Follow-up care among HIV-infected pregnant women in Mississippi

BACKGROUND

Data from the Centers for Disease Control and Prevention (CDC) indicate that reproductive-age black women in the Southeast are disproportionately affected by the HIV epidemic. There are few data describing HIV infection, pregnancies, and follow-up care in this population.

METHODS

A retrospective chart review was performed at the Perinatal HIV Service at the University of Mississippi Medical Center in Jackson, Mississippi, to identify HIV-infected women ≥ 18 years of age with deliveries from 1999 to 2006. Optimal follow-up was defined as at least two follow-up visits with an HIV provider within 1 year of delivery. Univariate and multivariate logistic regression analyses were used to identify factors associated with optimal adherence.

RESULTS

We identified 274 women with 297 total deliveries. Median age was 25, and 89% were black. Only 37% of women had two or more visits with an HIV provider in the postpartum year. On univariate analysis, presentation before the third trimester was associated with optimal follow-up (p = 0.04). On multivariate analyses, presentation before the third trimester was the only variable associated with optimal follow-up (odds ratio [OR] 2.1, p = 0.02).

CONCLUSIONS

The poor follow-up rates in this growing population highlight the critical need for research and development of targeted interventions to improve rates of retention in care, particularly in women with late trimester presentation.

HIV Drug Resistance Profiles and Clinical Outcomes in Patients with Viremia Maintained at Very Low Levels

We describe an observational study of clinical, virologic and drug resistance profiles in HIV-positive antiretroviral adherent subjects with stable low level viremia (LLV) 50-1,000 copies/mL for more than 12 months. Subjects were followed from time of first detectable viral load (VL). In total, 102 episodes of LLV were detected among 80 individuals. The median (mean, range) HIV copy number at genotyping was 250 (486, <50-3900) copies/mL after 14 (17.9, 0-58) months of LLV. Few patients maintained LLV for the entire 9 year period of observation, with half (52%) experiencing viremic progression following a stable period of LLV either spontaneously or after treatment interruption or failed regimen intensification. In the setting of prolonged periods of sustained LLV, mean duration 22 (range 8 - 106) months, drug resistance (DR) was almost universal. Resistance to ≥1 on-treatment drugs was defined in 97% of specimens and DR to all drugs in the treatment regimen in over half of all patients. Evolution of DR mutations during the period of LLV was observed in 20/28 (71%) subjects with specimens available for follow-up testing. This evolution was associated with viremic progression to levels >1000 copies/mL (p=0.03). Our data suggest that DR present in patients with LLV is likely to impact long term clinical outcomes, highlighting the importance of optimizing techniques to detect the presence of drug resistant HIV in the setting of LLV and the need for larger prospective studies to assess the emergence of DR in the setting of sustained LLV and the impact of this DR on treatment outcomes.

Interventions to improve retention in HIV primary care: a systematic review of U.S. studies

Retaining HIV-diagnosed persons in care is a national priority, but little is known on what intervention strategies are most effective for promoting retention in care. We conducted a systematic search and qualitatively reviewed 13 published studies and three recent conference presentations to identify evidence-informed retention strategies. We extracted information on study design, methods, and intervention characteristics. Strengths-based case management that encourages clients to recognize and use their own internal abilities to access resources and solve problems offered strong evidence for retention in care. Other evidence-informed strategies included peer navigation, reducing structural- and system-level barriers, including peers as part of a health care team, displaying posters and brochures in waiting rooms, having medical providers present brief messages to patients, and having clinics stay in closer contact with patients across time. Opportunities for additional intervention strategies include using community-based organizations as a setting for engaging HIV-infected persons about the importance of regular care and involving patients' significant others in retention in care interventions.

Effects of HIV Medication Complexity and Depression on Adherence to HIV Medication

BACKGROUND

: While much is known about the association between drug regimen complexity and drug adherence, little is known about how this association is affected by patient depression.

OBJECTIVE

: To examine whether the relationship between medication adherence and highly active antiretroviral therapy (HAART) regimen complexity varied with mental health status.

METHODS

: The analysis included 1192 respondents to HCSUS who were receiving HAART at the second HCSUS follow-up interview (1997-8). Self-reported past-week HAART adherence, current mental health status, and an aggregate measure of regimen complexity were used in the analysis. Regression models with interactions between mental health status and medication complexity were estimated to assess differential associations with adherence.

RESULTS

: Patients with high depressive/anxiety symptoms had lower odds of adherence to HAART medication (odds ratio [OR] = 0.78; p < 0.05) than those with low depressive symptoms at mean medication complexity. However, this association was found to vary by HAART medication complexity. Under high depressive symptoms, odds of adhering to a low-complexity regimen were 9% lower than odds of adhering to a regimen of mean complexity (OR = 0.91). Under low depressive symptoms, odds of adhering to a low-complexity regimen were 44% higher than for a regimen of mean complexity (OR = 1.44). In contrast, odds of adhering to a highly complex regimen compared with a regimen of mean complexity were 10% higher under high depressive symptoms (OR = 1.10) and 30% lower for low depressive symptoms (OR = 0.70). Thus, high levels of depression have ORs for adherence that increase with HIV drug complexity, while low levels of depression have ORs for adherence that decline with HIV drug complexity (the two trends differ by p = 0.10). In a second measure of mental health, similar results were found between low and high emotional well-being (the two trends differ by p < 0.05).

CONCLUSION

: While individuals with poorer mental health generally have poor adherence, these individuals may have been preferentially targeted with adherence support interventions as the medication regimen complexity increased. Physicians should now begin to target adherence interventions to patients with less complex HIV regimens.

Hepatitis B vaccine antibody response and the risk of clinical AIDS or death

BACKGROUND

Whether seroresponse to a vaccine such as hepatitis B virus (HBV) vaccine can provide a measure of the functional immune status of HIV-infected persons is unknown.This study evaluated the relationship between HBV vaccine seroresponses and progression to clinical AIDS or death.

METHODS AND FINDINGS

From a large HIV cohort, we evaluated those who received HBV vaccine only after HIV diagnosis and had anti-HBs determination 1-12 months after the last vaccine dose. Non-response and positive response were defined as anti-HBs <10 and ≥ 10 IU/L, respectively. Participants were followed from date of last vaccination to clinical AIDS, death, or last visit. Univariate and multivariable risk of progression to clinical AIDS or death were evaluated with Cox regression models. A total of 795 participants vaccinated from 1986-2010 were included, of which 41% were responders. During 3,872 person-years of observation, 122 AIDS or death events occurred (53% after 1995). Twenty-two percent of non-responders experienced clinical AIDS or death compared with 5% of responders (p<0.001). Non-response to HBV vaccine was associated with a greater than 2-fold increased risk of clinical AIDS or death (HR 2.47; 95% CI, 1.38-4.43) compared with a positive response, after adjusting for CD4 count, HIV viral load, HAART use, and delayed type hypersensitivity skin test responses (an in vivo marker of cell-mediated immunity). This association remained evident among those with CD4 count ≥ 500 cells/mm³ (HR 3.40; 95% CI, 1.39-8.32).

CONCLUSIONS

HBV vaccine responses may have utility in assessing functional immune status and risk stratificating HIV-infected individuals, including those with CD4 count ≥ 500 cells/mm³.

Cervical pap screening cytological abnormalities among HIV-infected adolescents in the LEGACY cohort

OBJECTIVES

To determine the prevalence of cervical Pap screening (CPAP-S), identify factors associated with CPAP-S, and explore risk factors for abnormal cervical cytology in female adolescents with perinatally and behaviorally acquired HIV infection.

DESIGN

Cross-sectional.

SETTING

LEGACY is a national observational cohort chart review study of 1478 HIV-infected persons (<age 24 years) managed in 22 HIV specialty clinics in the United States.

PARTICIPANTS

Sexually active females aged 13-24 years in the LEGACY cohort.

MAIN OUTCOME MEASURES

CPAP-S and abnormal cervical cytology.

RESULTS

Of 231 sexually active female LEGACY participants 13-24 years of age 49% had documentation of CPAP-S between 2001 and 2006. Fifty-eight percent of 113 cervical tests were abnormal (2% high-grade). In multivariable analysis, perinatal HIV infection and black race were associated with decreased likelihood of CPAP-S (adjusted prevalence ratio [APR] 0.66, 95% CI 0.45-0.96 and APR 0.74, 95% CI 0.56-0.96, respectively). Presence of any sexually transmitted infection (STI) was independently associated with increased likelihood of CPAP-S (APR 1.56, 95% CI 1.21, 2.02). CD4+ T-lymphocyte count <200 cells/mL and previous STI diagnosis were independently associated with increased likelihood of abnormal cervical cytology (APR 2.19, 95% CI 1.26-3.78 and APR 1.94, 95% CI 1.29-2.92, respectively).

CONCLUSIONS

Among sexually active HIV-infected adolescent females, prevalence of CPAP-S was low and cytology was abnormal in more than half of Pap smears. Perinatally HIV-infected, sexually active females were less likely to undergo CPAP-S than their behaviorally HIV-infected counterparts. Interventions targeted at HIV-infected adolescents and care providers are needed to improve CPAP-S in HIV-infected young women, especially those with perinatally acquired HIV infection.

Influenza A/H1N1 vaccination of patients with SLE: can antimalarial drugs restore diminished response under immunosuppressive therapy?

OBJECTIVE

To assess the efficacy and safety of pandemic 2009 influenza A (H1N1) in SLE under different therapeutic regimens.

METHODS

A total of 555 SLE patients and 170 healthy controls were vaccinated with a single dose of a non-adjuvanted preparation. According to current therapy, patients were initially classified as SLE No Therapy (n = 75) and SLE with Therapy (n = 480). Subsequent evaluations included groups under monotherapy: chloroquine (CQ) (n = 105), prednisone (PRED) ≥20 mg (n = 76), immunosuppressor (IS) (n = 95) and those with a combination of these drugs. Anti-H1N1 titres and seroconversion (SC) rate were evaluated at entry and 21 days post-vaccination.

RESULTS

The SLE with Therapy group had lower SC compared with healthy controls (59.0 vs 80.0%; P < 0.0001), whereas the SLE No Therapy group had equivalent SC (72 vs 80.0%; P = 0.18) compared with healthy controls. Further comparison revealed that the SC of SLE No Therapy (72%) was similar to the CQ group (69.5%; P = 0.75), but it was significantly reduced in PRED ≥20 mg (53.9%; P = 0.028), IS (55.7%; P = 0.035) and PRED ≥20 mg + IS (45.4%; P = 0.038). The concomitant use of CQ in each of these later regimens was associated with SC responses comparable with SLE No Therapy group (72%): PRED ≥20 mg + CQ (71.4%; P = 1.00), IS + CQ (65.2%; P = 0.54) and PRED ≥20 mg + IS + CQ (57.4%; P = 0.09).

CONCLUSION

Pandemic influenza A H1N1/2009 vaccine response is diminished in SLE under immunosuppressive therapy and antimalarials seems to restore this immunogenicity. Trial registration. www.clinicaltrials.gov, NCT01151644.

Is inadequate human immunodeficiency virus care associated with increased ED and hospital utilization? A prospective study in human immunodeficiency virus-positive ED patients

BACKGROUND

There is a lack of data on the effect(s) of suboptimal human immunodeficiency virus (HIV) care on subsequent health care utilization among emergency department (ED) patients with HIV. Findings on their ED and inpatient care utilization patterns will provide information on service provision for those who have suboptimal access to HIV-related care.

METHODS

A pilot prospective study was conducted on HIV-positive patients in an ED. At enrollment, participants were interviewed regarding health care utilization. Participants were followed up for 1 year, during which time data on ED visits and hospitalizations were obtained from their patient records. Inadequate HIV care (IHC) was defined according to Infectious Diseases Society of America recommendations as less than 3 scheduled clinic visits for HIV care in the year before enrollment. Cox regression models were used to evaluate whether IHC was associated with increased hazard of health care utilization.

RESULTS

Of 107 subjects, 36% were found to have IHC. Inadequate HIV care did not predict more frequent ED visits but was significantly associated with fewer hospitalizations (adjusted incidence rate ratio, 0.61 [95% CI: 0.43-0.86]). Inadequate HIV care did not significantly increase the hazard for earlier ED visit or hospitalization. However, further stratification analysis found that IHC increased the hazard of hospitalization for subjects without comorbid diseases (adjusted hazard ratio, 2.50 [95% CI: 1.10-5.68]).

CONCLUSIONS

In our setting, IHC does not appear to be associated with earlier or more frequent ED visits but may lead to earlier hospitalization, particularly among those without other chronic diseases.

STD screening of HIV-infected MSM in HIV clinics

BACKGROUND

National guidelines for the care of human immunodeficiency virus (HIV)-infected persons recommend asymptomatic routine screening for sexually transmitted diseases (STDs). Our objective was to determine whether providers who care for HIV-infected men who have sex with men (MSM) followed these guidelines.

METHODS

We abstracted medical records to evaluate STD screening at 8 large HIV clinics in 6 US cities. We estimated the number of men who had at least one test for syphilis, chlamydia (urethral and/or rectal), or gonorrhea (urethral, rectal, and/or pharyngeal) in 2004, 2005, and 2006. Urethral testing included nucleic acid amplification tests of both urethral swabs and urine. We also calculated the positivity of syphilis, chlamydia, and gonorrhea among screened men.

RESULTS

Medical records were abstracted for 1334 HIV-infected MSM who made 14,659 visits from 2004-2006. The annual screening rate for syphilis ranged from 66.0% to 75.8% during 2004-2006. Rectal chlamydia and rectal and pharyngeal gonorrhea annual screening rates ranged from 2.3% to 8.5% despite moderate to high positivity among specimens from asymptomatic patients (3.0%-9.8%) during this period. Annual urethral chlamydia and gonorrhea screening rates were higher than rates for nonurethral sites, but were suboptimal, and ranged from 13.8% to 18.3%.

CONCLUSIONS

Most asymptomatic HIV-infected MSM were screened for syphilis, indicating good provider adherence to this screening guideline. Low screening rates for gonorrhea and chlamydia, especially at rectal and pharyngeal sites, suggest that substantial barriers exist for complying with these guidelines. The moderate to high prevalence of asymptomatic chlamydial and gonococcal infections underscores the importance of screening. A range of clinical quality improvement interventions are needed to increase screening, including increasing the awareness of nucleic acid amplification tests for nonurethral screening.

Excess mortality among injection drug users with AIDS, New York City (1999-2004)

We calculated proportions and trends in contributing causes of death among persons with AIDS (PWA) and a history of injection drug use (IDU) in New York City and compared the proportions with those among PWA with a transmission risk of high-risk heterosexual sex (HRH) and men who have sex with men (MSM). We included all 10,575 injection drug user, HRH, and MSM residents aged 13+ years with AIDS reported by September 30, 2006 , who died from 1999 through 2004. Accidental drug overdose was the most frequent contributing cause of death among IDUs (20.5%). Overdose prevention initiatives may greatly and immediately reduce deaths among PWA.

Clinical management of acute HIV infection: best practice remains unknown

Best practice for the clinical management of acute human immunodeficiency virus (HIV) infection remains unknown. Although some data suggest possible immunologic, virologic, or clinical benefit of early treatment, other studies show no difference in these outcomes over time, after early treatment is discontinued. The literature on acute HIV infection is predominantly small nonrandomized studies, which further limits interpretation. As a result, the physician is left to grapple with these uncertainties while making clinical decisions for patients with acute HIV infection. Here we review the literature, focusing on the potential advantages and disadvantages of treating acute HIV infection outlined in treatment guidelines, and summarize the presentations on clinical management of acute HIV infection from the 2009 Acute HIV Infection Meeting in Boston, Massachusetts.

Poor immunogenicity of the H1N1 2009 vaccine in well controlled HIV-infected individuals

OBJECTIVE

To evaluate the safety and immunogenicity of the H1N1 2009 vaccine in HIV-positive individuals.

DESIGN

A single-arm study.

SETTING

Clinic at the Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA.

PARTICIPANTS

HIV-infected adults with an indication for H1N1 vaccination.

INTERVENTION

Single intramuscular 15 microg dose of the monovalent, unadjuvanted, inactivated, split virus H1N1 vaccine.

MAIN OUTCOMES

Immunogenicity, safety and tolerability.

RESULTS

A total of 120 participants were enrolled, 71% men, 68% African-American, with median age of 46 years. All of them but one were on antiretroviral treatment, with a median current CD4 cell counts of 502 cells/microl, and a nadir CD4 cell counts of 132 cells/microl. The HIV RNA level was below 400 copies/ml in 92% of participants. All participants completed the 3 weeks of follow-up. Thirty of the 120 (25%) participants had antibody hemagglutination-inhibition assay titers equal or greater than 1: 40 at baseline. Among participants without evidence of previous exposure, only 61% develop protective titers by week 3 of the study. Nonresponders had lower current and nadir CD4 cell counts than responders. Only four of nine participants with detectable HIV viral load at baseline developed protective antibody titers. Age and race were not predictors of the response to the vaccine. The vaccine was well tolerated.

CONCLUSION

These results suggest that only 60% of well controlled HIV-infected individuals without preexisting immunity to H1N1 develop protective antibody titers after immunization. Alternative vaccines, dosing, adjuvants or schedule strategies are needed to achieve effective immunization of this vulnerable population.