HIV disease and advanced age: an increasing therapeutic challenge

Risk Factors for Colorectal Cancer in Inpatients With Ulcerative Colitis: A Nationwide Cross-Sectional Analysis

Objectives

The objective is to study the demographic and geographical factors that increase the risk of colorectal cancer (CRC) in inpatients with ulcerative colitis (UC) and evaluate the mortality risk and hospitalization outcomes in terms of length of stay (LOS) and cost of care in patients with CRC in UC.

Methods

We conducted a cross-sectional study using the nationwide inpatient sample (NIS, 2019). We included 78,835 inpatients (age 15-65 years) hospitalized on emergency-based admissions with a primary diagnosis of UC. The study sample was divided by the presence of CRC. Categorical and continuous data were analyzed using Pearson’s chi-square test and independent-sample t-test respectively. Independent binomial logistic regression models were used to evaluate the odds ratio (OR) of predictors associated with CRC in patients with UC compared to non-CRC.

Results

The prevalence of CRC in inpatients with UC was 0.2%, and the mean age for admission of patients with UC with CRC was 49.6 years (SD ± 10.29). A directly proportionate relationship exists between increasing age and the risk of CRC in UC inpatients with 10 times higher odds seen in 51-65 years of age (OR 10.0, 95% CI 5.11-19.61). Males (OR 2.15, 95% CI 1.49-3.08) and Hispanics (OR 1.69, 95% CI 1.04-2.74) are at higher odds for CRC compared to their counterparts. Acquired immunodeficiency syndrome (AIDS) was associated with increased odds (OR 6.23, 95% CI 2.48-15.68) for CRC in UC inpatients. There existed an increased association for CRC in UC inpatients with complicated hypertension, and alcohol and drug abuse but was statistically non-significant. As per the adjusted regression model, CRC in UC inpatients increased the risk of in-hospital mortality (OR 41.09, 95% CI 19.49-86.58).

Conclusions

CRC was more prevalent in middle-aged Caucasian males with UC and those with chronic comorbidities including complicated diabetes and hypertension, alcohol abuse, and AIDS. Patients with UC and AIDS were found to have greater odds of developing CRC. A high index of clinical suspicion is needed in the management of these patient groups as the inpatient mortality risk was higher in UC inpatients with CRC.

HIV Neuropathogenesis in the Presence of a Disrupted Dopamine System

Antiretroviral therapy (ART) has transformed HIV into a chronic condition, lengthening and improving the lives of individuals living with this virus. Despite successful suppression of HIV replication, people living with HIV (PLWH) are susceptible to a growing number of comorbidities, including neuroHIV that results from infection of the central nervous system (CNS). Alterations in the dopaminergic system have long been associated with HIV infection of the CNS. Studies indicate that changes in dopamine concentrations not only alter neurotransmission, but also significantly impact the function of immune cells, contributing to neuroinflammation and neuronal dysfunction. Monocytes/macrophages, which are a major target for HIV in the CNS, are responsive to dopamine. Therefore, defining more precisely the mechanisms by which dopamine acts on these cells, and the changes in cellular function elicited by this neurotransmitter are necessary to develop therapeutic strategies to treat neuroHIV. This is especially important for vulnerable populations of PLWH with chemically altered dopamine concentrations, such as individuals with substance use disorder (SUD), or aging individuals using dopamine-altering medications. The specific neuropathologic and neurocognitive consequences of increased CNS dopamine remain unclear. This is due to the complex nature of HIV neuropathogenesis, and logistical and technical challenges that contribute to inconsistencies among cohort studies, animal models and in vitro studies, as well as lack of demographic data and access to human CNS samples and cells. This review summarizes current understanding of the impact of dopamine on HIV neuropathogenesis, and proposes new experimental approaches to examine the role of dopamine in CNS HIV infection. Graphical abstract HIV Neuropathogenesis in the Presence of a Disrupted Dopamine System. Both substance abuse disorders and the use of dopaminergic medications for age-related diseases are associated with changes in CNS dopamine concentrations and dopaminergic neurotransmission. These changes can lead to aberrant immune function, particularly in myeloid cells, which contributes to the neuroinflammation, neuropathology and dysfunctional neurotransmission observed in dopamine-rich regions in HIV+ individuals. These changes, which are seen despite the use antiretroviral therapy (ART), in turn lead to further dysregulation of the dopamine system. Thus, in individuals with elevated dopamine, the bi-directional interaction between aberrant dopaminergic neurotransmission and HIV infection creates a feedback loop contributing to HIV associated neurocognitive dysfunction and neuroHIV. However, the distinct contributions and interactions made by HIV infection, inflammatory mediators, ART, drugs of abuse, and age-related therapeutics are poorly understood. Defining more precisely the mechanisms by which these factors influence the development of neurological disease is critical to addressing the continued presence of neuroHIV in vulnerable populations, such as HIV-infected older adults or drug abusers. Due to the complexity of this system, understanding these effects will require a combination of novel experimental modalities in the context of ART. These will include more rigorous epidemiological studies, relevant animal models, and in vitro cellular and molecular mechanistic analysis.

Associated factors for progression to AIDS among HIV-infected people who use drugs: a retrospective cohort study in Dongguan, China

OBJECTIVES

Injection drug use is the most important risk factor for the spread of HIV in China over the past two decades. People who use drugs (PWUD) who were diagnosed at an early stage with HIV have gradually developed AIDS. This study investigated the factors associated with disease progression following HIV diagnosis in PWUD.

DESIGN

This study used a retrospective cohort study.

SETTING

This investigation was conducted in Dongguan city, Guangdong Province, China.

PARTICIPANTS

A total of 2969 PWUD with HIV were recruited from 1 January 1995 to 31 December 2014.

PRIMARY AND SECONDARY OUTCOME MEASURES

Kaplan-Meier method, Logistic regression and Cox proportional hazards regression model were applied to identify the related factors of progression to AIDS following HIV diagnosis.

RESULTS

The study revealed that age at diagnosis, marital status, baseline CD4 T-cell counts and highly active antiretroviral therapy (HAART) were statistically significant (p<0.01), either in the patients with HIV or in patients with AIDS. Compared with HIV-infected individuals of 18 years, patients with AIDS who were at least 36 years of age possessed sharply increased HR for developing AIDS (HR=7.016, 95% CI 6.083 to 8.092, p=0.001). The single HIV-positive individuals (HR=0.691, 95% CI 0.588 to 0.811, p=0.001) were less likely to develop AIDS compared with married ones. Increasing baseline CD4 T-cell counts, HAART (HR=0.599, 95% CI 0.517 to 0.693, p=0.001) and condom usage (HR=0.825, 95% CI 0.710 to 0.959, p=0.012) were associated with delayed progression to AIDS.

CONCLUSIONS

Our study found that increasing baseline CD4 T-cell counts, HAART and condom usage might be associated with delayed the progression of HIV to AIDS, while increasing age at diagnosis, marital status increased hazard for developing AIDS.

Expert consensus statement on the science of HIV in the context of criminal law

INTRODUCTION

Globally, prosecutions for non-disclosure, exposure or transmission of HIV frequently relate to sexual activity, biting, or spitting. This includes instances in which no harm was intended, HIV transmission did not occur, and HIV transmission was extremely unlikely or not possible. This suggests prosecutions are not always guided by the best available scientific and medical evidence.

DISCUSSION

Twenty scientists from regions across the world developed this Expert Consensus Statement to address the use of HIV science by the criminal justice system. A detailed analysis of the best available scientific and medical research data on HIV transmission, treatment effectiveness and forensic phylogenetic evidence was performed and described so it may be better understood in criminal law contexts. Description of the possibility of HIV transmission was limited to acts most often at issue in criminal cases. The possibility of HIV transmission during a single, specific act was positioned along a continuum of risk, noting that the possibility of HIV transmission varies according to a range of intersecting factors including viral load, condom use, and other risk reduction practices. Current evidence suggests the possibility of HIV transmission during a single episode of sex, biting or spitting ranges from no possibility to low possibility. Further research considered the positive health impact of modern antiretroviral therapies that have improved the life expectancy of most people living with HIV to a point similar to their HIV-negative counterparts, transforming HIV infection into a chronic, manageable health condition. Lastly, consideration of the use of scientific evidence in court found that phylogenetic analysis alone cannot prove beyond reasonable doubt that one person infected another although it can be used to exonerate a defendant.

CONCLUSIONS

The application of up-to-date scientific evidence in criminal cases has the potential to limit unjust prosecutions and convictions. The authors recommend that caution be exercised when considering prosecution, and encourage governments and those working in legal and judicial systems to pay close attention to the significant advances in HIV science that have occurred over the last three decades to ensure current scientific knowledge informs application of the law in cases related to HIV.

HIV Persistence on Antiretroviral Therapy and Barriers to a Cure

HIV persists within the body despite successful suppression of virus replication with antiretroviral therapy (ART). HIV lurks in latent and active reservoirs, leading to rebound of virus spread if ART is interrupted. The latent HIV reservoir is a natural consequence of the life cycle of HIV, with integration of HIV into the genomes of cells that are or later enter the resting state, resulting in transcriptionally quiescent provirus. Resting CD4 T cells comprise the majority of the latent reservoir, although new evidence points to additional, smaller cellular reservoirs of latent HIV. An alternate, so-called active reservoir of HIV also exists within cells such as those found the B cell follicle of lymph nodes, where expression of HIV RNA can be found, again despite the full suppression of viremia and viral replication. Multiple factors such as the degree of virus exposure, timing of ART, and host factors can influence the size and characteristics of the HIV reservoir. Constructing effective strategies for HIV eradication and measuring their impact will require a sophisticated knowledge of the HIV reservoir.

HIV Infection and Compromised Mucosal Immunity: Oral Manifestations and Systemic Inflammation

Mucosal surfaces account for the vast majority of HIV transmission. In adults, HIV transmission occurs mainly by vaginal and rectal routes but rarely via oral route. By contrast, pediatric HIV infections could be as the result of oral route by breastfeeding. As such mucosal surfaces play a crucial role in HIV acquisition, and spread of the virus depends on its ability to cross a mucosal barrier. HIV selectively infects, depletes, and/or dysregulates multiple arms of the human immune system particularly at the mucosal sites and causes substantial irreversible damage to the mucosal barriers. This leads to microbial products translocation and subsequently hyper-immune activation. Although introduction of antiretroviral therapy (ART) has led to significant reduction in morbidity and mortality of HIV-infected patients, viral replication persists. As a result, antigen presence and immune activation are linked to “inflammaging” that attributes to a pro-inflammatory environment and the accelerated aging process in HIV patients. HIV infection is also associated with the prevalence of oral mucosal infections and dysregulation of oral microbiota, both of which may compromise the oral mucosal immunity of HIV-infected individuals. In addition, impaired oral immunity in HIV infection may predispose the patients to periodontal diseases that are associated with systemic inflammation and increased risk of cardiovascular diseases. The purpose of this review is to examine existing evidence regarding the role of innate and cellular components of the oral cavity in HIV infection and how HIV infection may drive systemic hyper-immune activation in these patients. We will also discuss current knowledge on HIV oral transmission, HIV immunosenescence in relation to the oral mucosal alterations during the course of HIV infection and periodontal disease. Finally, we discuss oral manifestations associated with HIV infection and how HIV infection and ART influence the oral microbiome. Therefore, unraveling how HIV compromises the integrity of the oral mucosal tissues and innate immune components of the oral cavity and its association with induction of chronic inflammation are critical for the development of effective preventive interventions and therapeutic strategies.

HIV Infection and Compromised Mucosal Immunity: Oral Manifestations and Systemic Inflammation

Mucosal surfaces account for the vast majority of HIV transmission. In adults, HIV transmission occurs mainly by vaginal and rectal routes but rarely via oral route. By contrast, pediatric HIV infections could be as the result of oral route by breastfeeding. As such mucosal surfaces play a crucial role in HIV acquisition, and spread of the virus depends on its ability to cross a mucosal barrier. HIV selectively infects, depletes, and/or dysregulates multiple arms of the human immune system particularly at the mucosal sites and causes substantial irreversible damage to the mucosal barriers. This leads to microbial products translocation and subsequently hyper-immune activation. Although introduction of antiretroviral therapy (ART) has led to significant reduction in morbidity and mortality of HIV-infected patients, viral replication persists. As a result, antigen presence and immune activation are linked to "inflammaging" that attributes to a pro-inflammatory environment and the accelerated aging process in HIV patients. HIV infection is also associated with the prevalence of oral mucosal infections and dysregulation of oral microbiota, both of which may compromise the oral mucosal immunity of HIV-infected individuals. In addition, impaired oral immunity in HIV infection may predispose the patients to periodontal diseases that are associated with systemic inflammation and increased risk of cardiovascular diseases. The purpose of this review is to examine existing evidence regarding the role of innate and cellular components of the oral cavity in HIV infection and how HIV infection may drive systemic hyper-immune activation in these patients. We will also discuss current knowledge on HIV oral transmission, HIV immunosenescence in relation to the oral mucosal alterations during the course of HIV infection and periodontal disease. Finally, we discuss oral manifestations associated with HIV infection and how HIV infection and ART influence the oral microbiome. Therefore, unraveling how HIV compromises the integrity of the oral mucosal tissues and innate immune components of the oral cavity and its association with induction of chronic inflammation are critical for the development of effective preventive interventions and therapeutic strategies.

Prospective, Open-Label Comparative Study of Liver Toxicity in an Unselected Population of HIV-Infected Patients Treated for the First Time with Efavirenz or Nevirapine

OBJECTIVE

To compare the two nonnucleoside reverse transcriptase inhibitors (NNRTIs) when first introduced in an antiretroviral regimen, a prospective open-label assessment of the frequency, severity, risk factors, and outcome of hepatotoxicity was performed.

METHOD

Liver enzymes were followed-up during 18 months in patients who received efavirenz (EFV; 324 patients) or nevirapine (NVP; 299).

RESULTS

The two study groups were comparable, except for the lower baseline CD4+ count found in the EFV group. No differences were found when considering the type and duration of eventual prior anti-HIV therapy; frequency and length of protease inhibitors, methadone, or anti-tubercular drug use; HCV-HBV co-infection; other hepatobiliary disorders; and alcohol-drug abuse. The frequency of overall and first-month drug interruption proved similar in the two study groups. A hepatotoxicity characterized by at least a 2-fold increase of transaminases versus baseline was significantly linked with NVP, and the number of patients showing hepatotoxicity tended to a reduction in the EFV group. Also the time to peak transaminase alterations was shorter in the NVP group. All significant differences regarding liver-pancreatic toxicities were controlled per eventual baseline hepatobiliary-pancreatic diseases, HIV stage, and concurrent drug therapies.

DISCUSSION

Hepatotoxicity is a significant concern in the setting of antiretroviral-treated HIV disease. NVP-based HAART may be more hepatotoxic than EFV-based HAART, and a role is played by chronic liver disorders. Although concurrent hepatobiliary disorders and the possible hepatotoxicity of antiretrovirals do not represent contraindications to nonnucleoside inhibitor use, strict monitoring is recommended.

Sex, age, race and intervention type in clinical studies of HIV cure: a systematic review

This systematic review was undertaken to determine the extent to which adult subjects representing sex (female), race (nonwhite), and age (>50 years) categories are included in clinical studies of HIV curative interventions and thus, by extension, the potential for data to be analyzed that may shed light on the influence of such demographic variables on safety and/or efficacy. English-language publications retrieved from PubMed and from references of retrieved papers describing clinical studies of curative interventions were read and demographic, recruitment year, and intervention-type details were noted. Variables of interest included participation by sex, age, and race; changes in participation rates by recruitment year; and differences in participation by intervention type. Of 151 publications, 23% reported full demographic data of study enrollees, and only 6% reported conducting efficacy analyses by demographic variables. Included studies recruited participants from 1991 to 2011. No study conducted safety analyses by demographic variables. The representation of women, older people, and nonwhites did not reflect national or international burdens of HIV infection. Participation of demographic subgroups differed by intervention type and study location. Rates of participation of demographic groups of interest did not vary with time. Limited data suggest efficacy, particularly of early therapy initiation followed by treatment interruption, may vary by demographic variables, in this case sex. More data are needed to determine associations between demographic characteristics and safety/efficacy of curative interventions. Studies should be powered to conduct such analyses and cure-relevant measures should be standardized.

Outcomes in older versus younger patients over 96 weeks in HIV-1- infected patients treated with rilpivirine or efavirenz in ECHO and THRIVE

Objectives:

Increasing life expectancy of HIV-1–infected patients raises interest in how trial results apply to older patients. This post-hoc analysis evaluated potential differences in efficacy and safety in older (≥50 years) versus younger (<50 years) patients in the ECHO and THRIVE trials over 96 weeks.

Methods:

HIV-infected, treatment-naÏve adults were randomized to receive rilpivirine (RPV) or efavirenz (EFV), plus a background regimen. Virologic response rates (FDA snapshot analysis; HIV-1 RNA <50 copies/mL) were assessed at Week 96. Total-body bone mineral density was evaluated at baseline and Week 96 by dual-energy X-ray absorptiometry scans. Serum concentrations of 25-hydroxy vitamin D (ECHO trial only) were also measured at baseline, Week 24 and Week 48.

Results:

1368 patients were treated. At Week 96, virologic response rates were similar between older (77%) and younger (76%) RPV-treated patients and numerically higher in older (84%) versus younger (76%) EFV-treated patients. No clinically relevant age-related differences were observed in immunologic responses. Small differences were noted in older versus younger patients in adverse events (higher rates of depression, insomnia, and rash in older EFV-treated patients), laboratory abnormalities (increased low-density lipoprotein cholesterol and hyperglycemia in older EFV-treated patients and increased amylase in older patients across treatments), bone mineral density (larger decreases in older patients across treatments), and progression to severe vitamin D deficiency (greater in older versus younger EFV-treated patients).

Conclusion:

Efficacy and safety outcomes were generally similar in older versus younger patients in the ECHO and THRIVE trials.

Characteristics and outcomes among older HIV-positive adults enrolled in HIV programs in four sub-Saharan African countries

Background

Limited information exists on adults ≥50 years receiving HIV care in sub-Saharan Africa.

Methodology

Using routinely-collected longitudinal patient-level data among 391,111 adults ≥15 years enrolling in HIV care from January 2005–December 2010 and 184,689 initiating ART, we compared characteristics and outcomes between older (≥50 years) and younger adults at 199 clinics in Kenya, Mozambique, Rwanda, and Tanzania. We calculated proportions over time of newly enrolled and active adults receiving HIV care and initiating ART who were ≥50 years; cumulative incidence of loss to follow-up (LTF) and recorded death one year after enrollment and ART initiation, and CD4+ response following ART initiation.

Findings

From 2005–2010, the percentage of adults ≥50 years newly enrolled in HIV care remained stable at 10%, while the percentage of adults ≥50 years newly initiating ART (10% [2005]-12% [2010]), active in follow-up (10% [2005]-14% (2010]), and active on ART (10% [2005]-16% [2010]) significantly increased. One year after enrollment, older patients had significantly lower incidence of LTF (33.1% vs. 32.6%[40–49 years], 40.5%[25–39 years], and 56.3%[15–24 years]; p-value<0.0001), but significantly higher incidence of recorded death (6.0% vs. 5.0% [40–49 years], 4.1% [25–39 years], and 2.8% [15–24 years]; p-valve<0.0001). LTF was lower after vs. before ART initiation for all ages, with older adults experiencing less LTF than younger adults. Among 85,763 ART patients with baseline and follow-up CD4+ counts, adjusted average 12-month CD4+ response for older adults was 20.6 cells/mm³ lower than for adults 25–39 years of age (95% CI: 17.1–24.1).

Conclusions

The proportion of patients who are ≥50 years has increased over time and been driven by aging of the existing patient population. Older patients experienced less LTF, higher recorded mortality and less robust CD4+ response after ART initiation. Increased programmatic attention on older adults receiving HIV care in sub-Saharan Africa is warranted.

What's pregnancy got to do with it? Late presentation to HIV/AIDS services in Northeastern Brazil

Despite the known benefits of early treatment initiation for individual morbidity and mortality, as well as for reducing the risk of transmission, late presentation (LP) to HIV/AIDS services remains a major concern in many countries. There is little information on LP from middle- and low-income countries and studies that do evaluate LP commonly disaggregate data by sex. It is rare, however, for researchers to further disaggregate the data by pregnancy status so it remains unclear if pregnancy status modifies the effects associated with sex. The study was conducted at the only State Reference Center for HIV/AIDS in Salvador, Brazil's third largest city. LP was defined as a patient accessing services with a CD4 < 350 cells/mm(3). Data were abstracted from the electronic medical records of 1421 patients presenting between 2007 and 2009. CD4 counts and viral load (VL) information was validated with data from the National CD4/VL Database. Descriptive and bivariate statistics were conducted to inform the multivariate analysis. Adjusted prevalence ratios (APR) were estimated using generalized linear models due to the high frequency of the outcome. Half of the sample (52.5%; n = 621) was classified as LP. Compared to the prevalence among pregnant women (21.1%), the prevalence of LP was more than twice as high among non-pregnant women (56.0%) and among men (55.4%). The multivariate analysis demonstrated no statistical difference between men and nonpregnant women (APR 1.04; 95%CI 0.92-1.19), but the APR of LP for nonpregnant women was 53% less than men (APR 0.47; 95%CI 0.33-0.68). These results highlight the importance of analyzing data disaggregated not only by sex but also by pregnancy status to accurately identify the risk factors associated with LP so that programs and policies can effectively and efficiently address LP in Brazil and beyond.

Determinants of progression to AIDS and death following HIV diagnosis: a retrospective cohort study in Wuhan, China

OBJECTIVE

To identify determinants associated with disease progression and death following human immunodeficiency virus (HIV) diagnosis.

METHODS

Disease progression data from the diagnosis of HIV infection or acquiring immunodeficiency syndrome (AIDS) to February 29, 2012 were retrospectively collected from the national surveillance system databases and the national treatment database in Wuhan, China. Kaplan-Meier method, Logistic regression and Cox proportional hazards model were applied to identify the related factors of progression to AIDS or death following HIV diagnosis.

RESULTS

By the end of February 2012, 181 of 691 HIV infectors developed to AIDS, and 129 of 470 AIDS patients died among whom 289 cases received concurrent HIV/AIDS diagnosis. Compared with men infected through homosexual behavior, injection drug users possessed sharply decreased hazard ratio (HR) for progression to AIDS following HIV diagnosis [HR = 0.31, 95% confidence interval (CI), 0.18-0.54, P = 4.01×10(-5)]. HIV infectors at least 60 years presented 1.15-fold (HR = 2.15, 95% CI, 1.15-4.03, P = 0.017) increased risk to develop AIDS when compared with those aged 17-29 years. Similarly, AIDS patients with diagnosis ages between 50 and 59 years were at a 1.60-fold higher risk of death (HR = 2.60, 95% CI, 1.18-5.72, P = 0.017) compared to those aged 19-29 years. AIDS patients with more CD4(+) T-cells within 6 months at diagnosis (cell/µL) presented lower risk of death (HR = 0.29 for 50- vs <50, 95% CI, 0.15-0.59, P = 0.001). The highly active antiretroviral therapy (HAART) delayed progression to AIDS from HIV diagnosis (HR = 0.15, 95% CI, 0.07-0.34, P = 6.46×10(-6)) and reduced the risk of death after AIDS diagnosis (HR = 0.02, 95% CI, 0.01-0.04, P = 7.25×10(-25)).

CONCLUSIONS

Progression to AIDS and death following HIV diagnosis differed in age at diagnosis, transmission categories, CD4(+) T-cell counts and HAART. Effective interventions should target those at higher risk for morbidity or mortality, ensuring early diagnosis and timely treatment to slow down the disease progression.

High rates of late HIV diagnosis among people who inject drugs compared to men who have sex with men and heterosexual men and women in Australia

We aimed to estimate temporal trends in the proportion of HIV diagnoses which could be characterized as recent infections in Australia for men who have sex with men (MSM), people who inject drugs (PWID), and heterosexual men and women using modified back-projection methodology based on data sources from HIV/AIDS Surveillance database. The proportion of HIV diagnoses among MSM that can be classified as recent infections increased in MSM, heterosexual men and women consistently. However, after initial increases during 1996-2000, the proportion of overall recent infections estimated among PWID declined by 50% in 2007 compared to 2000 (from 23 to 11%). These data suggest that late HIV diagnoses were more common among PWID compared to other groups. Ongoing prevention efforts need to be coupled with targeted testing and treatment efforts to increase the diagnosis of recent infection in PWID and reduce apparent inequities in access to screening.

Epidemiology of HIV among Asians and Pacific Islanders in the United States, 2001-2008

BACKGROUND

Recent analyses have shown increases in combined annual HIV diagnosis rates for Asians and Pacific Islanders (API).

METHODS

Using surveillance data from 33 states and 4 dependent areas we investigated the epidemiology of HIV among API during 2001-2008.

RESULTS

HIV diagnoses for API during 2001-2008 were predominantly among persons age 30-39 years (40%) and males (78%). The primary risk factor for males was sexual contact with males (78%) and for females, heterosexual contact (86%). API were the only racial/ethnic groups with a statistically significant estimated annual percentage increase (4.4%) in HIV diagnoses over the time period. Thirty-seven percent of HIV diagnoses among API progressed to AIDS in <12 months, with significantly greater likelihood among those 30 years and older. Survival was lower among API with AIDS diagnosis after 49 years of age, and was higher among persons with AIDS whose primary risk factor for infection was heterosexual contact.

CONCLUSIONS

In contrast to other racial/ethnic groups, API were the only groups to show a significant increase in HIV diagnoses. A clearer understanding of the reasons for this trend is needed, so that appropriate interventions can be selected and adapted to prevent increased HIV prevalence among API in the U.S.

The effect of aging, nutrition, and exercise during HIV infection

Medical advances continue to change the face of human immunodeficiency virus- acquired immunodeficiency syndrome (HIV/AIDS). As life expectancy increases, the number of people living with HIV rises, presenting new challenges for the management of a chronic condition. Aging, nutrition, and physical activity can influence outcomes in other chronic conditions, and emerging data show that each of these factors can impact viral replication and the immune system in HIV. HIV infection results in a decline of the immune system through the depletion of CD4+ T cells. From initial infection, viral replication is a continuous phenomenon. Immunosenescence, a hallmark of aging, results in an increased susceptibility to infections secondary to a delayed immune response, and this phenomenon may be increased in HIV-infected patients. Optimal nutrition is an important adjunct in the clinical care of patients with HIV. Nutritional interventions may improve the quality and span of life and symptom management, support the effectiveness of medications, and improve the patient's resistance to infections and other disease complications by altering immunity. Moderate physical activity can improve many immune parameters, reduce the risk of acute infection, and combat metabolic abnormalities. As people with HIV age, alternative therapies such as nutrition and physical activity may complement medical management.

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

OBJECTIVE

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

DESIGN

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Recent trends for colorectal cancer screening in HIV-infected patients

We planned to investigate the recent trends for colorectal cancer (CRC) screening in human immunodeficiency virus (HIV) as compared to non-HIV by interviewing consecutive patients in outpatient clinics during September 2007. Out of a total of 300 patients interviewed, 205 met the inclusion criteria. One hundred and fourteen were HIV-infected, while 91 were non-HIV. HIV received more office visits per year. Despite the high incidence of adenomas on screening colonoscopy, HIV patients were less likely to undergo any type of CRC screening test. A higher number (>or=10) of annual clinic visits and the presence of co-morbid conditions were associated with being up-to-date for CRC screening in HIV patients. Conclusion CRC screening is underutilized in HIV patients. Multiple office visits per year are associated with being up-to-date for CRC screening. Hence, increasing patients' compliance with office visits and educating them about the importance of CRC screening may indirectly increase compliance with CRC screening.

[HIV Infection in the elderly]

HIV infection is increasingly common in the elderly. This population is a heterogeneous group with particular epidemiologic characteristics and often with associated comorbidities, which frequently delay diagnosis and lead to poor immunological status at the start of highly active antiretroviral therapy (HAART). There are no differences between elderly and young HIV infected patients in the recommended antiretroviral regimens. Tolerance to treatment is good and the virological and immunological response to HAART is positive, although immunological response is slower and lower than in younger patients. Treatment adherence, which has been shown to be the only protective independent factor related to virological failure, is better in the elderly.

Late HIV diagnosis and determinants of progression to AIDS or death after HIV diagnosis among injection drug users, 33 US States, 1996-2004

Background

The timeliness of HIV diagnosis and the initiation of antiretroviral treatment are major determinants of survival for HIV-infected people. Injection drug users (IDUs) are less likely than persons in other transmission categories to seek early HIV counseling, testing, and treatment. Our objective was to estimate the proportion of IDUs with a late HIV diagnosis (AIDS diagnosis within 12 months of HIV diagnosis) and determine the factors associated with disease progression after HIV diagnosis.

Methodology/Principal Findings

Using data from 33 states with confidential name-based HIV reporting, we determined the proportion of IDUs aged ≥13 years who received a late HIV diagnosis during 1996–2004. We used standardized Kaplan-Meier survival methods to determine differences in time of progression from HIV to AIDS and death, by race/ethnicity, sex, age group, CD4⁺ T-cell count, metropolitan residence, and diagnosis year. We compared the survival of IDUs with the survival of persons in other transmission categories. During 1996–2004, 42.2% (11,635) of 27,572 IDUs were diagnosed late. For IDUs, the risk for progression from HIV to AIDS 3 years after HIV diagnosis was greater for nonwhites, males and older persons. Three-year survival after HIV diagnosis was lower for IDU males (87.3%, 95% confidence interval (CI), 87.1–87.4) compared with males exposed through male-to-male sexual contact (91.6%, 95% CI, 91.6–91.7) and males exposed through high-risk heterosexual contact (HRHC) (91.9%, 95% CI, 91.8–91.9). Survival was also lower for IDU females (89.5%, 95% CI, 89.4–89.6) compared to HRHC females (93.3%, 95% CI, 93.3–93.4).

Conclusions/Significance

A substantial proportion of IDUs living with HIV received their HIV diagnosis late. To improve survival of IDUs, HIV prevention efforts must ensure early access to HIV testing and care, as well as encourage adherence to antiretroviral treatment to slow disease progression.

Infection: is it a cause of bladder cancer?

This article reviews the literature regarding the possible correlation between infection and occurrence of bladder cancer. The PubMed literature database was searched from inception to January 2008. Keywords of bladder, cancer, parasitic, bacterial, viral and infection, were used. Forty studies were included in the review. Several investigators support the idea that schistosomiasis is aetiologically related to the development of bladder cancer in individuals infected with Schistosoma haematobium. Approximately 70% of those with chronic schistosomiasis who have bladder cancer develop squamous cell rather than transitional cell carcinoma. Several investigators suggest that bacteria may play a role in inducing bladder cancer. Clinically, researchers have linked the development of infection, urinary stones and indwelling catheters with bladder cancer. Nevertheless, to date, no prospective study has examined the association between urinary tract infection and bladder cancer risk. The possibility that infection by human papilloma virus (HPV) is a risk factor contributing to bladder cancer has been investigated but no definite conclusions have been drawn. Thus, the debate remains open as to whether there is any direct link between chronic HPV infection and bladder cancer. Only 15 cases of vesical carcinoma have been reported, to date, in the setting of human immunodeficiency virus (HIV). The rare occurrence of bladder cancer during HIV infection and the lack of correlation with the laboratory markers of HIV disease progression may suggest a trivial association between two unrelated disorders. BK virus is oncogenic in newborn hamsters and can transfer to mammalian cells in vitro, but there is little consistent evidence of a link with human bladder cancer. Studies showed no correlation between herpes simplex virus (HSV) and bladder cancer, but bladder cancer becomes infected with HSV much more easily than non-neoplastic urothelium. In conclusion, with the exception of chronic infection with S. haematobium, the association between the occurrence of bladder cancer and chronic bacterial or viral infections could not be confirmed. Prospective studies with large numbers of patients and controls are required to confirm this issue.

Epidemiology of HIV and response to antiretroviral therapy in the middle aged and elderly

HIV is increasing in prevalence in the middle aged and older population owing to both increased longevity, and new infections in these populations. Highly active antiretrorival therapy (HAART) therapy may be less effective at restoring immune function in older patients compared with younger patients. There are significant toxicities associated with HAART therapy that, combined with decreased renal and liver function in older patients, may be more problematic in older HIV-infected patients. Comorbid disease is becoming an increasing problem with coadministration of multiple drugs and significant drug-drug interactions. Psychosocial issues in the older patient are often different than those in younger HIV-infected patients and providers should try to address these issues early. Finally, future research should work to identify the ideal timing and type of HAART regimens for older HIV-infected individuals.

Mortality of the elderly is still exceedingly high at diagnosis of AIDS despite favourable outcomes after highly active antiretroviral therapy in Recife, Brazil

This study aimed to compare the outcome of an elderly group of AIDS patients with that of a younger group and their features at the time of the diagnosis of AIDS. We evaluated 58 patients aged >60 years and 114 aged 20-39 years, followed for 35.3 months. There was an obvious delay in diagnosing the elderly as they had more AIDS-defining diseases at diagnosis and their most frequent opportunistic infection was pulmonary tuberculosis. Mortality at the time of the diagnosis of AIDS was four times higher in the elderly (24.1% versus 6.1%, P < 0.001). However, when comparing only those submitted to highly active antiretroviral therapy, there was a similar frequency of favourable outcomes; 76.9% in the elderly against 83.1% in the young (P = 0.455). Mean CD4 lymphocyte was 438 cells/mm(3) at the end of follow up in the young when compared with 442 cells/mm(3) in the elderly (P = 0.945). The types of antiretroviral schema and the number of antivirals per patient were similar in both groups.

The eldest of older adults living with HIV: response and adherence to highly active antiretroviral therapy

OBJECTIVE

The study objective was to analyze the characteristics and the response to therapy in the eldest of the older adults living with human immunodeficiency virus.

METHODS

The study included a cohort of patients with human immunodeficiency virus aged 55 years or more on initiating highly active antiretroviral therapy (HAART). Immunologic and virologic response, morbidity, and mortality were assessed. Patients were categorized as aged less than 65 years and 65 years or more.

RESULTS

A total of 112 patients were included (82 patients aged<65 years and 30 patients aged> or =65 years). There were no differences between the age groups in baseline characteristics, survival, and virologic response. There was a trend toward better adherence and a lower CD4+ cell increase after HAART in the older group.

CONCLUSION

A relationship was found between lower CD4+ cell increase after HAART and advanced age. We found the best adherence to treatment in the eldest of the older adults, and this has been shown to be the only protective independent factor related to virologic failure.

HIV infection in the elderly

In the US, an estimated 1 million people are infected with HIV, although one-third of this population are unaware of their diagnosis. While HIV infection is commonly thought to affect younger adults, there are an increasing number of patients over 50 years of age living with the condition. UNAIDS and WHO estimate that of the 40 million people living with HIV/AIDS in the world, approximately 2.8 million are 50 years and older. With the introduction of highly active antiretroviral therapy (HAART) in the mid-1990s, survival following HIV diagnosis has risen dramatically and HIV infection has evolved from an acute disease process to being managed as a chronic medical condition. As treated HIV-infected patients live longer and the number of new HIV diagnoses in older patients rise, clinicians need to be aware of these trends and become familiar with the management of HIV infection in the older patient. This article is intended for the general clinician, including geriatricians, and will review epidemiologic data and HIV treatment as well as provide a discussion on medical management issues affecting the older HIV-infected patient.

HIV infection in older adults

The incidence and prevalence of HIV infection in older adults is rising, with disproportionate increases in women and minorities. Compared with younger adults, older patients who have HIV often are diagnosed later in the course of the disease and may have an accelerated decline in immune function. Although the prognosis for older adults has improved with the initiation of highly active antiretroviral therapy, there remains a higher risk for comorbid illness. Additional efforts to diagnose and prevent HIV infection in this older age group are necessary to decrease the transmission of HIV and to reduce the morbidity and mortality associated with this infection.

The challenge of managing drug interactions in elderly people

Drug therapy is essential when caring for elderly patients, but clearly it is a double-edged sword. Elderly patients are at high risk of having drug interactions, but the prevalence of these interactions is not well documented. Several types of interactions exist: drug-drug, drug-disease, drug-food, drug-alcohol, drug-herbal products, and drug-nutritional status. Factors such as age-related changes in pharmacokinetics and pharmacodynamics, frailty, interindividual variability, reduced homoeostatic mechanisms, and psychosocial issues need to be considered when drug interactions are assessed. Software can help clinicians to detect drug interactions, but many programmes have not been updated with the evolving knowledge of these interactions, and do not take into consideration important factors needed to optimise drug treatment in elderly patients. Any generated recommendations have to be tempered by a holistic, geriatric, multiprofessional approach that is team-based. This second paper in a series of two on prescribing in elderly people proposes an approach to categorise drug interactions, along with strategies to assist in their detection, management, and prevention.

Older women's attitudes, behavior, and communication about sex and HIV: a community-based study

OBJECTIVES

To examine the effects of race and marriage on the sexual attitudes, behavior, and patient-physician communication about sexuality and HIV/AIDS among older women.

METHODS

This was a cross-sectional survey of 55 community-residing women aged 58-93.

RESULTS

57% of respondents had engaged in sexual activity since the 60th birthday. Nearly 60% of single women who had been sexually active in the previous 10 years reported that they had not used a condom; 21% of women with a current sexual partner agreed that condom use is not necessary "if you can no longer get pregnant." African American women were significantly more likely to report making changes in their sexual behavior due to HIV (53% vs. 19% white, p = 0.02). Married and African American women were more likely to discuss sex with a physician (80% vs. 47%; p = 0.03 and 75% vs. 46%, p = 0.05, respectively). African Americans were more likely to have had a physician initiate such a discussion (69% vs. 38%, p = 0.04).

CONCLUSIONS

Older women in this sample were sexually active, engaged in potentially risky sexual behavior, and believed that physicians should address issues of sexuality. Older African American women were significantly more likely than white women to report HIV-related changes in their behavior and to discuss sex with a physician. This community-based study corroborates clinical research and suggests both a gap and a disparity in older women's dialogue with physicians. It also indicates the need for more broadly generalizable data on issues pertinent to older women's sexual health.

Determinants of progression to AIDS or death after HIV diagnosis, United States, 1996 to 2001

PURPOSE

The aim of the study is to determine factors associated with disease progression after human immunodeficiency virus (HIV) infection diagnosis.

METHODS

We applied generalized linear models with Poisson errors to obtain adjusted relative excess risk for death for persons diagnosed with acquired immunodeficiency syndrome (AIDS) or HIV infection (with or without concurrent AIDS) during 1996 to 2001. We examined differences in time between HIV diagnosis and AIDS by using standardized Kaplan-Meier survival methods.

RESULTS

Relative excess risk for death within 3 years after AIDS diagnosis was significantly greater for non-Hispanic blacks (1.15; 95% confidence interval [CI], 1.12-1.18), American Indians (1.33; 95% CI, 1.16-1.52), and Hispanics (1.16; 95% CI, 1.13-1.20) compared with whites. Risk for death also was greater among injection drug users (men, 1.50; 95% CI, 1.46-1.54; women, 1.57; 95% CI, 1.51-1.62) compared with men who have sex with men and among those diagnosed at older ages compared with younger persons. Similar disparities between groups in risk for death were observed from HIV diagnosis. Risk for progression from HIV to AIDS was greater for nonwhites, men, and older persons compared with whites, women, and younger persons, respectively.

CONCLUSIONS

Interventions should target those at excess risk for death or morbidity to ensure access to quality care and adherence to treatment to slow disease progression.

HIV after age 55

HIV/AIDS continues to increase among adults older than 50 years of age. Racial and ethnic minorities are still disproportionately affected by HIV/AIDS. The misconception that older adults are not at high risk for acquiring HIV/AIDS stems from a false impression that older adults are not sexually active and do not participate in risky behaviors that could result in HIV/AIDS. Studies show that older adult men and women engage in sexual intercourse--or some form of sexual behavior--at least weekly, and identify that risk factors for HIV/AIDS among adults older than 50 years of age include multiple sex partners, a high-risk partner, receipt of blood products between 1974 and 1984, or injection drug use. The development of new diagnostic resources, antimicrobial treatments, and antiretroviral therapy have made HIV/AIDS more chronic in nature, so that morbidity and mortality rates related to HIV/AIDS have declined. With this decline, HIV/AIDS has become a disease of chronicity rather than an acute illness.

Bladder carcinoma and HIV infection during the highly active antiretroviral therapy era: A rare, but intriguing association. Two case reports and literature review

Two very rare case reports of bladder transitional cell carcinoma associated with HIV infection in patients treated with combined antiretroviral therapy are described, and discussed on the ground of the most relevant and updated literature resources. Only 13 cases of vesical carcinoma have been reported to date in the setting of HIV infection, but only 3 anecdotal single reports (the last in the y 2001) described clinical, therapeutic, and outcome issues of this rare disease association in some detail. In our patients, micro- or macro-haematuria was the clue for in-depth diagnosis and prompt treatment, which was limited to multiple local interventions in 1 case, but finally required a radical cystectomy in the second patient. No relationship was found with the very favourable underlying HIV-related virological and immunological status, and the present 8-12-month follow-up did not show disease relapses.

HIV and Aging

Between 2001 and 2004, the percentage of all HIV cases in patients aged >or=50 years increased from 17% to 23%. This concerning increase is expected to continue over the next decade. The increasing prevalence of HIV in these patients is a result of increased longevity in patients treated with highly active antiretroviral therapy (HAART) as well as new primary infections in older patients. While older patients may achieve virological suppression at the same rate as younger patients, the immunological benefit of HAART in older patients may be reduced compared with younger patients. In addition, the toxicities associated with HAART may be worse in older HIV patients, particularly those with underlying renal or hepatic insufficiency. All previous studies evaluating the virological and immunological benefits of HAART in older patients have had relatively small sample sizes and none has compared efficacy or rates of toxicity by HAART treatment class. Co-morbidities are more common in older than in younger patients and can impact on the management of HIV in these patients. Providers must be cognisant of drug-drug interactions and potential adverse effects of HAART regimens when selecting an ideal antiretroviral regimen for older HIV patients. Given the increased longevity and rates of malignancies in HIV-infected patients, providers should also be particularly vigilant in maintaining routine health screening in older HIV patients. Controlled trials on HIV epidemiology, pathogenesis, and therapeutic and clinical outcomes are also needed in older patients. As the HIV-infected population ages, there is a growing need to better determine the effectiveness of HAART in older patients, and to investigate factors associated with a more rapid course of HIV infection in patients aged >50 years.

Aging and HIV infection

With the advent of highly active antiretroviral therapy (HAART) in mid-1995, the prognosis for HIV-infected individuals has brightened dramatically. However, the conjunction of potent antiviral therapy and longer life expectancy may engender a variety of health risks that, heretofore, HIV specialists have not had to confront. The long-term effects of HIV infection itself and exposure to antiretroviral agents is unknown. Several aspects of aging, including psychiatric disease, neurocognitive impairment, and metabolic and hormonal disorders, may be influenced by chronic exposure to HIV and/or HIV therapeutics. In this paper, we discuss the health issues confronting HIV-infected older adults and areas for future research.

HIV infection in older patients in the HAART era

An increasing number of patients over 50 years of age are now living with HIV, owing to highly active antiretroviral therapy (HAART) that prolongs survival on the one hand and to late diagnosis of patients living with occult HIV infection on the other hand. Most studies have shown that compared with younger patients, patients over 50 generally have a slower immunological response to HAART and experience more rapid clinical progression, despite a better virological response. Low thymic output probably plays a role in the poorer CD4 cell response in patients initiating HAART over 50 years. Management of HIV infection in older patients is particularly complex, mainly because they are more likely to have co-morbidities necessitating specific medications that may interact with antiretroviral drugs. More controlled studies of HAART efficacy and tolerability in such patients are needed to establish specific management guidelines. Information campaigns targeting older patients and their doctors are also needed to ensure timely diagnosis of HIV infection and antiretroviral treatment initiation.

Colorectal cancer screening in HIV-infected patients 50 years of age and older: missed opportunities for prevention

OBJECTIVES

Although human immunodeficiency virus (HIV)-infected patients are now living longer, there are no published data on colorectal cancer (CRC) screening in this population. We hypothesized that HIV-infected patients were less likely to be screened for CRC compared to patients without HIV.

METHODS

Consecutive HIV-infected patients > or =50 yr old seen in our outpatient clinic from 1/1/01 to 6/30/02 were identified. For each HIV-infected patient, we selected one age- and gender-matched control subject without HIV infection who was seen during the same time period. The electronic medical records were reviewed to determine the proportion of patients that had a fecal occult blood test (FOBT), flexible sigmoidoscopy, air-contrast barium enema (ACBE), or colonoscopy.

RESULTS

During the 18-month study period, 538 HIV-infected outpatients were seen and 302 (56.1%) were > or =50 yr old. Despite significantly more visits with their primary care provider, HIV-infected patients were less likely to have ever had at least one CRC screening test (55.6%vs 77.8%, p < 0.001). The proportion of HIV-infected patients who ever had a FOBT (43.0%vs 66.6%, p < 0.001), flexible sigmoidoscopy (5.3%vs 17.5%, p < 0.001), ACBE (2.6%vs 7.9%, p= 0.004), or colonoscopy (17.2%vs 27.5%, p= 0.002) was significantly lower than in control subjects. In addition, HIV-infected patients were significantly less likely to be up-to-date with at least one CRC screening test according to current guidelines (49.3%vs 65.6%, p < 0.001).

CONCLUSIONS

A substantial number of HIV-infected patients are > or =50 yr of age and CRC screening is underutilized in this population. Public health strategies to improve CRC screening in HIV-infected patients are needed.

Perspective on HIV infection and aging: emerging research on the horizon

A greater prevalence of human immunodeficiency virus (HIV)-infected individuals aged >50 years is projected. This epidemiologic trend will continue to increase as a result of not only greater survival rates among HIV-infected patients who receive treatment, but also of delayed recognition of older individuals with occult HIV disease. Historically, it was thought that, despite viral responses to highly active antiretroviral therapy (HAART) among older individuals that approximate those of younger individuals, older persons infected with HIV could not mount as vigorous an immune response as do younger HIV-infected individuals. However, recent evidence suggests that older HIV-infected individuals may do just as well, because they may be more compliant with their antiretroviral regimens. Limited data are available on the safety and tolerability of HAART in this population. Emerging evidence suggests that metabolic, neuropsychiatric, and cardiovascular morbidities could be exacerbated by use of antiretrovirals or by HIV infection itself. Additional research is needed to optimize the care of older HIV-infected patients.

S-adenosylmethionine (SAM-e) for the treatment of depression in people living with HIV/AIDS

BACKGROUND

This study reports on clinical data from an 8-week open-label study of 20 HIV-seropositive individuals, diagnosed with Major Depressive Disorder (DSM-IV), who were treated with SAM-e (S-Adenosylmethionine). SAM-e may be a treatment alternative for the management of depression in a population reluctant to add another "pill" or another set of related side effects to an already complex highly active antiretroviral therapy (HAART) regimen.

METHODS

The Hamilton Rating Scale for Depression (HAM-D) and the Beck Depression Inventory (BDI) were used to assess depressive symptomatology from 1,2,4,6 and 8 weeks after initiation of treatment with SAM-e.

RESULTS

Data show a significant acute reduction in depressive symptomatology, as measured by both the HAM-D and the BDI instruments.

CONCLUSIONS

SAM-e has a rapid effect evident as soon as week 1 (p < .001), with progressive decreases in depression symptom rating scores throughout the 8 week study.

Changes in T cell receptor excision DNA circle (TREC) levels in HIV type 1-infected subjects pre- and post-highly active antiretroviral therapy

The T cell receptor excision DNA circle (TREC) level is an independent predictor of HIV-1 disease prognosis. We studied the temporal changes in TREC levels prior to and after highly active antiretroviral therapy (HAART) in a cohort of 131 Greek men with hemophilia who were followed up for up to 20 years since seroconversion (SC). TREC levels were determined in all available cryopreserved samples of peripheral blood mononuclear cells (PBMCs) using a multiplex real-time polymerase chain reaction (PCR) assay. Trends in log(10) TREC values were described using random effects models. Prior to HAART initiation TREC levels tended to decrease over time (mean rate of drop 19% per year; 95% CI: 16-22%). Initial TREC values were higher with younger age at SC, but the subsequent rate of drop did not differ significantly by age at SC. There was a monotonic relationship between baseline HIV-RNA levels and TREC slopes with steeper slopes at higher levels of HIV-RNA. The TREC slopes differed significantly by clinical outcome being steeper in subjects who progressed to AIDS sooner. After HAART initiation, TREC values tended to increase on average by 35% per year (95% CI: -7-94%) but the increase was evident only in subjects with a pre-HAART CD4 count below 80 cells/microl. TREC values, which likely represent a simple indicator of naive T-lymphocyte reserve, may be a clinically useful marker for long-term prognosis of HIV-1 infection and for immune reconstitution after successful HAART.