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Jensen FB, Thorpe D. Social Model Hospice: Providing Hospice and Palliative Care for a Homeless Population in Salt Lake City, Utah. J Hosp Palliat Nurs 2024; 26:91-97. [PMID: 37976394 DOI: 10.1097/njh.0000000000001000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2023]
Abstract
Health care for the homeless population is a complex challenge and represents a significant gap in care, particularly for those at the end of life. Hospice care may be desired but is rarely an option for people without residences, social support, and payment sources. Social model hospice is a unique paradigm of care delivery that offers a viable solution to make hospice and palliative care possible for this population. In this historical report from interviews with early organizers, prior and current leadership (n = 6), the evolution of The INN Between in Salt Lake City, Utah, is described. In 2010, The INN Between was conceptualized as a nonprofit community effort addressing this need to provide an alternative to people dying unsheltered. After 5 years of planning, it opened in 2015 and has grown to become a comprehensive community resource for homeless medically frail and terminally ill individuals. Recommendations for establishing social model hospices are made: key strategies include identifying stakeholders dedicated to alleviating end-of-life homelessness needs, doing a formal needs assessment to identify community resource deficits, and forming mentoring relationships with established programs. Social model hospice is a viable way of meeting the end-of-life needs of many communities' most vulnerable residents.
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Buchman DZ, Lo S, Ding P, Dosani N, Fazelzad R, Furlan AD, Isenberg SR, Spithoff S, Tedesco A, Zimmermann C, Lau J. Palliative care for people who use drugs during communicable disease epidemics and pandemics: A scoping review on access, policies, and programs and guidelines. Palliat Med 2023; 37:426-443. [PMID: 36522840 PMCID: PMC9760505 DOI: 10.1177/02692163221143153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND People who use drugs with life-limiting illnesses experience substantial barriers to accessing palliative care. Demand for palliative care is expected to increase during communicable disease epidemics and pandemics. Understanding how epidemics and pandemics affect palliative care for people who use drugs is important from a service delivery perspective and for reducing population health inequities. AIM To explore what is known about communicable disease epidemics and pandemics, palliative care, and people who use drugs. DESIGN Scoping review. DATA SOURCES We searched six bibliographic databases from inception to April 2021 as well as the grey literature. We included English and French records about palliative care access, programs, and policies and guidelines for people ⩾18 years old who use drugs during communicable disease epidemics and pandemics. RESULTS Forty-four articles were included in our analysis. We identified limited knowledge about palliative care for people who use drugs during epidemics and pandemics other than HIV/AIDS. Through our thematic synthesis of the records, we generated the following themes: enablers and barriers to access, organizational barriers, structural inequity, access to opioids and other psychoactive substances, and stigma. CONCLUSIONS Our findings underscore the need for further research about how best to provide palliative care for people who use drugs during epidemics and pandemics. We suggest four ways that health systems can be better prepared to help alleviate the structural barriers that limit access as well as support the provision of high-quality palliative care during future epidemics and pandemics.
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Affiliation(s)
- Daniel Z Buchman
- Everyday Ethics Lab, Centre for Addiction and Mental Health, Toronto, ON, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- University of Toronto Joint Centre for Bioethics, Toronto, ON, Canada
| | - Samantha Lo
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Philip Ding
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Naheed Dosani
- Department of Medicine, St Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada
- Palliative Education And Care for the Homeless (PEACH), Inner City Health Associates, Toronto, ON, Canada
- Division of Palliative Care, McMaster University, Hamilton, ON, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
| | - Rouhi Fazelzad
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Andrea D Furlan
- Toronto Rehab, University Health Network, Toronto, ON, Canada
- Department of Medicine, University of Toronto, Toronto, ON, Canada
- Institute for Work & Health, Toronto, ON, Canada
| | - Sarina R Isenberg
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
- Bruyère Research Institute, Ottawa, ON, Canada
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Sheryl Spithoff
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
- Women's College Hospital, Toronto, ON, Canada
| | - Alissa Tedesco
- Palliative Education And Care for the Homeless (PEACH), Inner City Health Associates, Toronto, ON, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
- Temmy Latner Centre for Palliative Care, Sinai Health System, Toronto, ON, Canada
| | - Camilla Zimmermann
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
- Department of Medicine, University of Toronto, Toronto, ON, Canada
- Division of Palliative Medicine, University of Toronto, ON, Canada
- Division of Palliative Care, University Health Network, Toronto, ON, Canada
| | - Jenny Lau
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
- Division of Palliative Care, University Health Network, Toronto, ON, Canada
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Freedman SF, Johnston C, Faragon JJ, Siegler EL, Del Carmen T. Older HIV-infected adults. Complex patients (III): Polypharmacy. Eur Geriatr Med 2018; 10:199-211. [PMID: 31983932 DOI: 10.1007/s41999-018-0139-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Polypharmacy is a well-described problem in the geriatric population. It is a relatively new problem for people living with HIV (PLWH), as this group now has a life expectancy approaching that of the general population. Defining polypharmacy for PLWH is difficult, since the most common traditional definition of at least five medications would encompass a large percentage of PLWH who are on antiretrovirals (ARVs) and medications for other medical comorbidities. Even when excluding ARVs, the prevalence of polypharmacy in PLWH is higher than the general population, and not just in resource-rich countries. Using a more nuanced approach with "appropriate" or "safer" polypharmacy allows for a better framework for discussing how to mitigate the associated risks. Some of the consequences of polypharmacy include adverse effects of medications including the risk of geriatric syndromes, drug-drug interactions, decreased adherence, and over- and undertreatment of medical comorbidities. Interventions to combat polypharmacy include decreasing pill burden-specifically with fixed-dose combination (FDC) tablets- and medication reconciliation/deprescription using established criteria. The goal of these interventions is to decrease drug interactions and improve quality of life and outcomes. Some special populations of interest within the community of PLWH include those with chronic pain, substance abuse, or requiring end of life care. A final look into the future of antiretroviral therapy (ART) shows the promise of possible two-drug regimens, which can help reduce the above risks of polypharmacy.
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Affiliation(s)
- Samuel F Freedman
- Department of Medicine, Weill Cornell Medicine, New York, New York, USA
| | - Carrie Johnston
- Division of Infectious Diseases, Weill Cornell Medicine, New York, New York, USA
| | | | - Eugenia L Siegler
- Division of Geriatrics and Palliative Medicine, Weill Cornell Medicine, New York, New York, USA
| | - Tessa Del Carmen
- Division of Geriatrics and Palliative Medicine, Weill Cornell Medicine, New York, New York, USA
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Peacock ME, Arce RM, Cutler CW. Periodontal and other oral manifestations of immunodeficiency diseases. Oral Dis 2017; 23:866-888. [PMID: 27630012 PMCID: PMC5352551 DOI: 10.1111/odi.12584] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2016] [Revised: 08/31/2016] [Accepted: 09/08/2016] [Indexed: 12/14/2022]
Abstract
The list of immunodeficiency diseases grows each year as novel disorders are discovered, classified, and sometimes reclassified due to our ever-increasing knowledge of immune system function. Although the number of patients with secondary immunodeficiencies (SIDs) greatly exceeds those with primary immunodeficiencies (PIDs), the prevalence of both appears to be on the rise probably because of scientific breakthroughs that facilitate earlier and more accurate diagnosis. Primary immunodeficiencies in adults are not as rare as once thought. Globally, the main causes of secondary immunodeficiency are HIV infection and nutritional insufficiencies. Persons with acquired immune disorders such as AIDS caused by the human immunodeficiency virus (HIV) are now living long and fulfilling lives as a result of highly active antiretroviral therapy (HAART). Irrespective of whether the patient's immune-deficient state is a consequence of a genetic defect or is secondary in nature, dental and medical practitioners must be aware of the constant potential for infections and/or expressions of autoimmunity in these individuals. The purpose of this review was to study the most common conditions resulting from primary and secondary immunodeficiency states, how they are classified, and the detrimental manifestations of these disorders on the periodontal and oral tissues.
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Affiliation(s)
- Mark E Peacock
- Associate Professor, Departments of Periodontics, Oral Biology
| | - Roger M. Arce
- Assistant Professor, Departments of Periodontics, Oral Biology
| | - Christopher W Cutler
- Professor, Departments of Periodontics, Oral Biology; Chair, Department of Periodontics, Associate Dean for Research, The Dental College of Georgia at Augusta University
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HIV-1 Evolutionary Patterns Associated with Metastatic Kaposi's Sarcoma during AIDS. Sarcoma 2016; 2016:4510483. [PMID: 27651732 PMCID: PMC5019946 DOI: 10.1155/2016/4510483] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2016] [Accepted: 08/07/2016] [Indexed: 12/19/2022] Open
Abstract
Kaposi's sarcoma (KS) in HIV-infected individuals can have a wide range of clinical outcomes, from indolent skin tumors to a life-threatening visceral cancer. KS tumors contain endothelial-related cells and inflammatory cells that may be HIV-infected. In this study we tested if HIV evolutionary patterns distinguish KS tumor relatedness and progression. Multisite autopsies from participants who died from HIV-AIDS with KS prior to the availability of antiretroviral therapy were identified at the AIDS and Cancer Specimen Resource (ACSR). Two patients (KS1 and KS2) died predominantly from non-KS-associated disease and KS3 died due to aggressive and metastatic KS within one month of diagnosis. Skin and visceral tumor and nontumor autopsy tissues were obtained (n = 12). Single genome sequencing was used to amplify HIV RNA and DNA, which was present in all tumors. Independent HIV tumor clades in phylogenies differentiated KS1 and KS2 from KS3, whose sequences were interrelated by both phylogeny and selection. HIV compartmentalization was confirmed in KS1 and KS2 tumors; however, in KS3, no compartmentalization was observed among sampled tissues. While the sample size is small, the HIV evolutionary patterns observed in all patients suggest an interplay between tumor cells and HIV-infected cells which provides a selective advantage and could promote KS progression.
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CD4+/CD8+ ratio, age, and risk of serious noncommunicable diseases in HIV-infected adults on antiretroviral therapy. AIDS 2016; 30:899-908. [PMID: 26959354 DOI: 10.1097/qad.0000000000001005] [Citation(s) in RCA: 83] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
OBJECTIVE In virologically suppressed HIV-infected adults, noncommunicable diseases (NCDs) have been associated with immune senescence and low CD4/CD8 lymphocyte ratio. Age differences in the relationship between CD4/CD8 ratio and NCDs have not been described. DESIGN Observational cohort study. METHODS We assessed CD4/CD8 ratio and incident NCDs (cardiovascular, cancer, liver, and renal diseases) in HIV-infected adults started on antiretroviral therapy between 1998 and 2012. Study inclusion began once patients maintained virologic suppression for 12 months (defined as baseline). We examined age and baseline CD4/CD8 ratio and used Cox proportional hazard models to assess baseline CD4/CD8 ratio and NCDs. RESULTS This study included 2006 patients. Low baseline CD4/CD8 ratio was associated with older age, male sex, and low CD4 lymphocyte counts. In models adjusting for CD4 lymphocyte count, CD4/CD8 ratio was inversely associated with age (P < 0.01). Among all patients, 182 had incident NCDs, including 46 with coronary artery disease (CAD) events. CD4/CD8 ratio was inversely associated with risk of CAD events [adjusted HR per 0.1 increase in CD4/CD8 ratio = 0.87, 95% confidence interval (CI): 0.76-0.99, P = 0.03]. This association was driven by those under age 50 years (adjusted HR 0.83 [0.70-0.97], P = 0.02) vs. those over age 50 years (adjusted HR = 0.96 [0.79-1.18], P = 0.71). CD4/CD8 ratio was not significantly associated with incident noncardiac NCDs. CONCLUSIONS Higher CD4/CD8 ratio after 1 year of HIV virologic suppression was independently predictive of decreased CAD risk, particularly among younger adults. Advanced immune senescence may contribute to CAD events in younger HIV patients on antiretroviral therapy.
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Simonik A, Vader K, Ellis D, Kesbian D, Leung P, Jachyra P, Chan Carusone S, O'Brien KK. Are you ready? Exploring readiness to engage in exercise among people living with HIV and multimorbidity in Toronto, Canada: a qualitative study. BMJ Open 2016; 6:e010029. [PMID: 26956163 PMCID: PMC4785327 DOI: 10.1136/bmjopen-2015-010029] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVES Our aim was to explore readiness to engage in exercise among people living with HIV and multimorbidity. DESIGN We conducted a descriptive qualitative study using face-to-face semistructured interviews with adults living with HIV. SETTING We recruited adults (18 years or older) who self-identified as living with HIV and 2 or more additional health-related conditions from a specialty hospital in Toronto, Canada. PARTICIPANTS 14 participants with a median age of 50 years and median number of 9 concurrent health-related conditions participated in the study. The majority of participants were men (64%) with an undetectable viral load (71%). OUTCOME MEASURES We asked participants to describe their readiness to engage in exercise and explored how contextual factors influenced their readiness. We analysed interview transcripts using thematic analysis. RESULTS We developed a framework to describe readiness to engage in exercise and the interplay of factors and their influence on readiness among adults with HIV and multimorbidity. Readiness was described as a diverse, dynamic and fluctuating spectrum ranging from not thinking about exercise to routinely engaging in daily exercise. Readiness was influenced by the complex and episodic nature of HIV and multimorbidity comprised of physical impairments, mental health challenges and uncertainty from HIV and concurrent health conditions. This key factor created a context within which 4 additional subfactors (social supports, perceptions and beliefs, past experience with exercise, and accessibility) may further hinder or facilitate an individual's position along the spectrum of readiness to exercise. CONCLUSIONS Readiness to engage in exercise among people living with HIV is a dynamic and fluctuating construct that may be influenced by the episodic nature of HIV and multimorbidity and 4 subfactors. Strategies to facilitate readiness to exercise should consider the interplay of these factors in order to enhance physical activity and subsequently improve health outcomes of people with HIV and multimorbidity.
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Affiliation(s)
- Alya Simonik
- Department of Physical Therapy, University of Toronto, Toronto, Ontario, Canada
| | - Kyle Vader
- Department of Physical Therapy, University of Toronto, Toronto, Ontario, Canada
| | - Denine Ellis
- Department of Physical Therapy, University of Toronto, Toronto, Ontario, Canada
| | - Dirouhi Kesbian
- Department of Physical Therapy, University of Toronto, Toronto, Ontario, Canada
| | - Priscilla Leung
- Department of Physical Therapy, University of Toronto, Toronto, Ontario, Canada
| | - Patrick Jachyra
- Rehabilitation Sciences Institute (RSI), University of Toronto, Toronto, Ontario, Canada
| | | | - Kelly K O'Brien
- Department of Physical Therapy, University of Toronto, Toronto, Ontario, Canada
- Rehabilitation Sciences Institute (RSI), University of Toronto, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation (IHPME), University of Toronto, Toronto, Ontario, Canada
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Cowell A, Shenoi SV, Kyriakides TC, Friedland G, Barakat LA. Trends in hospital deaths among human immunodeficiency virus-infected patients during the antiretroviral therapy era, 1995 to 2011. J Hosp Med 2015; 10:608-14. [PMID: 26130520 PMCID: PMC4560992 DOI: 10.1002/jhm.2409] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2015] [Revised: 05/22/2015] [Accepted: 05/27/2015] [Indexed: 12/27/2022]
Abstract
OBJECTIVE Mortality in hospitalized human immunodeficiency virus (HIV)-infected patients is not well described. We sought to characterize in-hospital deaths among HIV-infected patients in the antiretroviral (ART) era and identify factors associated with mortality. METHODS We reviewed the medical records of hospitalized HIV-infected patients who died from January 1, 1995 to December 31, 2011 at an urban teaching hospital. We evaluated trends in early and late ART use and deaths due to acquired immunodeficiency syndrome (AIDS) and non-AIDS, and identified clinical and demographic correlates of non-AIDS deaths. RESULTS In-hospital deaths declined significantly from 1995 to 2011 (P < 0.0001); those attributable to non-AIDS increased (43% to 70.5%, P < 0.0001). Non-AIDS deaths were most commonly caused by non-AIDS infection (20.3%), cardiovascular (11.3%) and liver disease (8.5%), and non-AIDS malignancy (7.8%). Patients with non-AIDS compared to AIDS-related deaths were older (median age 48 vs 40 years, P < 0.0001), more likely to be on ART (74.1% vs 55.8%, P = 0.0001), less likely to have a CD4 count of <200 cells/mm(3) (47.2% vs 97.1%, P < 0.0001), and more likely to have an HIV viral load of ≤400 copies/mL (38.1% vs 4.1%, P < 0.0001). Non-AIDS deaths were associated with 4.5 and 4.2 times greater likelihood of comorbid underlying liver and cardiovascular disease, respectively. CONCLUSIONS Non-AIDS deaths increased significantly during the ART era and are now the most common cause of in-hospital deaths; non-AIDS infection, cardiovascular and liver disease, and malignancies were major contributors to mortality. Higher CD4 cell count, liver, and cardiovascular comorbidities were most strongly associated with non-AIDS deaths. Interventions targeting non-AIDS-associated conditions are needed to reduce inpatient mortality among HIV-infected patients.
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Affiliation(s)
- Annie Cowell
- Department of Internal Medicine, Section of Infectious Diseases, University of California, San Diego, California
| | - Sheela V Shenoi
- Department of Internal Medicine, Section of Infectious Diseases, AIDS Program, Yale University School of Medicine, New Haven, Connecticut
| | - Tassos C Kyriakides
- Yale Center for Analytical Sciences, Yale School of Public Health, New Haven, Connecticut
| | - Gerald Friedland
- Department of Internal Medicine, Section of Infectious Diseases, AIDS Program, Yale University School of Medicine, New Haven, Connecticut
| | - Lydia Aoun Barakat
- Department of Internal Medicine, Section of Infectious Diseases, AIDS Program, Yale University School of Medicine, New Haven, Connecticut
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Bhattacharjya C, Sahu D, Kishor Patel S, Saggurti N, Pandey A. Causes of Death among HIV-Infected Adults Registered in Selected Anti-Retroviral Therapy Centers in North-Eastern India. ACTA ACUST UNITED AC 2015. [DOI: 10.4236/wja.2015.52011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Navarro J, Pérez M, Curran A, Burgos J, Feijoo M, Torrella A, Caballero E, Ocaña I, Ribera E, Crespo M, Falcó V. Impact of an adherence program to antiretroviral treatment on virologic response in a cohort of multitreated and poorly adherent HIV-infected patients in Spain. AIDS Patient Care STDS 2014; 28:537-42. [PMID: 25111167 DOI: 10.1089/apc.2014.0097] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Several studies have shown the importance of adherence to highly active antiretroviral therapy (HAART) in achieving HIV-1 suppression. However, most have focused on naïve patients and do not assess the impact of HAART on viral load (VL). Our aim was to evaluate the effectiveness of an adherence program in a cohort of multitreated and poorly adherent patients. We performed a cohort study of all adult HIV-1 infected patients with detectable VL who were treatment experienced and poorly adherent to HAART, included in an adherence program since its introduction in 2009 (n=136). The adherence program consisted of a multidisciplinary team with a nurse who specialized in behavioral intervention, counselling on substance abuse, and motivational interviewing, as well as a social worker responsible for referring patients to local healthcare centers. Effectiveness was evaluated as percentage of patients with VL <50 copies/mL at week 48 by modified intent-to-treat (mITT) analysis. Initially, 76.6% of the patients had an adherence <30% according to the Simplified Medication Adherence Questionnaire (SMAQ). At 48 weeks, 48.1% of the patients had VL <50 copies/mL, and the adherence was >90% in 71% of the patients. In multivariate analysis, a ratio of bottle refill per month >0.9 during the study [odds ratio (OR) 14.3; 95% confidence interval (CI) 4.08-50.08, p<0.001] and being on a b.i.d. regimen (OR 12.5; 95% CI 1.81-86.4, p=0.010) were associated with an undetectable VL. In conclusion, the adherence program was successful in almost half of the patients, despite their long treatment experience and prior poor adherence. This strategy may help to prevent disease progression and the risk of HIV transmission in these patients.
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Affiliation(s)
- Jordi Navarro
- Infectious Diseases Department, Hospital Universitari Vall d'Hebron, Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
- Infectious Diseases Department, Vall d'Hebron Research Institute, Barcelona, Spain
| | - Merce Pérez
- Infectious Diseases Department, Hospital Universitari Vall d'Hebron, Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Adria Curran
- Infectious Diseases Department, Hospital Universitari Vall d'Hebron, Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
- Infectious Diseases Department, Vall d'Hebron Research Institute, Barcelona, Spain
| | - Joaquin Burgos
- Infectious Diseases Department, Hospital Universitari Vall d'Hebron, Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Maria Feijoo
- Infectious Diseases Department, Hospital Universitari Vall d'Hebron, Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Ariadna Torrella
- Infectious Diseases Department, Hospital Universitari Vall d'Hebron, Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Estrella Caballero
- Microbiology Department, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Inma Ocaña
- Infectious Diseases Department, Hospital Universitari Vall d'Hebron, Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Esteban Ribera
- Infectious Diseases Department, Hospital Universitari Vall d'Hebron, Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Manel Crespo
- Infectious Diseases Department, Hospital Universitari Vall d'Hebron, Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Vicenç Falcó
- Infectious Diseases Department, Hospital Universitari Vall d'Hebron, Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
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Almodovar S. The complexity of HIV persistence and pathogenesis in the lung under antiretroviral therapy: challenges beyond AIDS. Viral Immunol 2014; 27:186-99. [PMID: 24797368 DOI: 10.1089/vim.2013.0130] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Antiretroviral therapy (ART) represents a significant milestone in the battle against AIDS. However, we continue learning about HIV and confronting challenges 30 years after its discovery. HIV has cleverly tricked both the host immune system and ART. First, the many HIV subtypes and recombinant forms have different susceptibilities to antiretroviral drugs, which may represent an issue in countries where ART is just being introduced. Second, even under the suppressive pressures of ART, HIV still increases inflammatory mediators, deregulates apoptosis and proliferation, and induces oxidative stress in the host. Third, the preference of HIV for CXCR4 as a co-receptor may also have noxious outcomes, including potential malignancies. Furthermore, HIV still replicates cryptically in anatomical reservoirs, including the lung. HIV impairs bronchoalveolar T-lymphocyte and macrophage immune responses, rendering the lung susceptible to comorbidities. In addition, HIV-infected individuals are significantly more susceptible to long-term HIV-associated complications. This review focuses on chronic obstructive pulmonary disease (COPD), pulmonary arterial hypertension, and lung cancer. Almost two decades after the advent of highly active ART, we now know that HIV-infected individuals on ART live as long as the uninfected population. Fortunately, its availability is rapidly increasing in low- and middle-income countries. Nevertheless, ART is not risk-free: the developed world is facing issues with antiretroviral drug toxicity, resistance, and drug-drug interactions, while developing countries are confronting issues with immune reconstitution inflammatory syndrome. Several aspects of the complexity of HIV persistence and challenges with ART are discussed, as well as suggestions for new avenues of research.
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Affiliation(s)
- Sharilyn Almodovar
- Pulmonary Sciences and Critical Care Medicine, University of Colorado Denver Anschutz Medical Campus , Aurora, Colorado
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12
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Continuous increase of cardiovascular diseases, diabetes, and non-HIV related cancers as causes of death in HIV-infected individuals in Brazil: an analysis of nationwide data. PLoS One 2014; 9:e94636. [PMID: 24728320 PMCID: PMC3984254 DOI: 10.1371/journal.pone.0094636] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2013] [Accepted: 03/18/2014] [Indexed: 12/28/2022] Open
Abstract
Introduction After antiretroviral therapy (ART) became available, there was a decline in the number of deaths in persons infected with HIV. Thereafter, there was a decrease in the proportion of deaths attributed to opportunistic infections and an increase in the proportion of deaths attributed to chronic comorbidities. Herein we extend previous observations from a nationwide survey on temporal trends in causes of death in HIV-infected patients in Brazil. Methods We describe temporal trends in causes of death among adults who had HIV/AIDS listed in the death certificate to those who did not. All death certificates issued in Brazil from 1999 to 2011 and listed in the national mortality database were included. Generalized linear mixed-effects logistic models were used to study temporal trends in proportions. Results In the HIV-infected population, there was an annual adjusted average increase of 6.0%, 12.0%, 4.0% and 4.1% for cancer, external causes, cardiovascular diseases (CVD) and diabetes mellitus (DM), respectively, compared to 3.0%, 4.0%, 1.0% and 3.9%, in the non-HIV group. For tuberculosis (TB), there was an adjusted average increase of 0.3%/year and a decrease of 3.0%/year in the HIV and the non-HIV groups, respectively. Compared to 1999, the odds ratio (OR) for cancer, external causes, CVD, DM, or TB in the HIV group were, respectively, 2.31, 4.17, 1.76, 2.27 and 1.02, while for the non-HIV group, the corresponding OR were 1.31, 1.63, 1.14, 1.62 and 0.67. Interactions between year as a continuous or categorical variable and HIV were significant (p<0.001) for all conditions, except for DM when year was considered as a continuous variable (p = 0.76). Conclusions Non HIV-related co-morbidities continue to increase more rapidly as causes of death among HIV-infected individuals than in those without HIV infection, highlighting the need for targeting prevention measures and surveillance for chronic diseases among those patients.
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Brigham EP, Patil SP, Jacobson LP, Margolick JB, Godfrey R, Johnson J, Johnson-Hill LM, Reynolds S, Schwartz AR, Smith PL, Brown TT. Association between systemic inflammation and obstructive sleep apnea in men with or at risk for HIV infection. Antivir Ther 2014; 19:725-33. [PMID: 24518040 PMCID: PMC4130807 DOI: 10.3851/imp2745] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/21/2014] [Indexed: 02/05/2023]
Abstract
BACKGROUND We sought to determine whether markers of systemic inflammation are associated with the presence of moderate/severe obstructive sleep apnea (OSA) and whether this association differs based on HIV and HIV treatment status. METHODS HIV-uninfected men (HIV-; n=60), HIV-infected men receiving HAART (HIV+/HAART; n=58) and HIV-infected men not receiving HAART (HIV+/no HAART; n=41) underwent polysomnograpy and measurement of plasma levels of tumour necrosis factor (TNF)-α, soluble TNF-α receptors I and II (sTNFRI and sTNFRII) and interleukin (IL)-6. The relationship between moderate/severe OSA (respiratory disturbance index ≥15 apnea/hypopnea events/h) and inflammatory markers was assessed with multivariable regression models. RESULTS Compared with the HIV- men, HIV+/HAART men and HIV+/no HAART men had higher levels of TNF-α, sTNFRI and sTNFRII, independent of age, race, smoking status, obstructive lung disease (OLD) and body mass index (BMI). Moderate/severe OSA was present in 48% of the sample (HIV- 57%; HIV+/HAART 41%; HIV+/no HAART 44%). Among the HIV+/no HAART men, but not in the other groups, TNF-α, sTNFRII and IL-6 levels were higher in those with moderate/severe OSA compared to men with no/mild OSA after adjustment for age, race, smoking status, OLD and BMI. Within this group, the association of high TNF-α concentrations with moderate/severe OSA was also independent of CD4(+) T-cell count and plasma HIV RNA concentration. CONCLUSIONS Compared with HIV+/HAART men and HIV- men, markers of systemic inflammation were higher in HIV+/no HAART men. In these men, TNF-α was significantly related to OSA, independent of HIV-related covariates.
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Affiliation(s)
- Emily P Brigham
- The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Susheel P Patil
- The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Lisa P Jacobson
- The Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | - Joseph B Margolick
- The Johns Hopkins University School of Medicine, Baltimore, MD, USA
- The Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | - Rebecca Godfrey
- The Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | - Jacquett Johnson
- The Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | | | - Sandra Reynolds
- The Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | - Alan R Schwartz
- The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Philip L Smith
- The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Todd T Brown
- The Johns Hopkins University School of Medicine, Baltimore, MD, USA
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14
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Kadima JN, Mukanyangezi MF, Uwizeye CB. Effectiveness and safety of concurrent use of first-line antiretroviral and antituberculous drugs in rwanda. J Trop Med 2014; 2014:904957. [PMID: 24624142 PMCID: PMC3929278 DOI: 10.1155/2014/904957] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2013] [Revised: 11/08/2013] [Accepted: 12/02/2013] [Indexed: 11/17/2022] Open
Abstract
Background. Overlapping toxicity between drugs used for HIV and TB could complicate the management of HIV/TB coinfected patients, particularly those carrying multiple opportunistic infections. This study aimed to evaluate the clinical outcomes and adverse drug events in HIV patients managed with first-line antiretroviral and first-line anti-TB drugs. Methods. This is a retrospective study utilizing medical dossiers from single-HIV infected and HIV/TB coinfected patients already initiated on ART. Predictors of outcomes included changes in CD4 cells/mm(3), body weight, physical improvement, death rate, and adverse drug reactions. Results. Records from 60 HIV patients and 60 HIV/TB patients aged between 20 and 58 years showed that all clinical indicators of effectiveness were better in single-HIV infected than in HIV/TB coinfected patients: higher CD4 cell counts, better physical improvement, and low prevalence of adverse drug events. The most frequently prescribed regimen was TDF/3TC/EFV+RHZE. The mortality rate was 20% in HIV/TB patients compared to 8.3% in the single-HIV group. Conclusion. Treatment regimens applied are efficient in controlling the progression of the infection. However, attention should be paid to adjust dosing when combining nonnucleoside antiretrovirals (EFV and NVR) with anti-TB drugs to minimize the risk of death by drug intoxication.
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Affiliation(s)
| | | | - Claude Bernard Uwizeye
- Infectious Diseases Unit, Department of Internal Medicine, Kigali University Teaching Hospital, Kigali, Rwanda
- Rwanda Biomedical Centre, Kigali, Rwanda
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