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Kahn JA, Belzer M, Chi X, Lee J, Gaur AH, Mayer K, Martinez J, Futterman DC, Stier EA, Paul ME, Chiao EY, Reirden D, Goldstone SE, Ortiz Martinez AP, Cachay ER, Barroso LF, Da Costa M, Wilson CM, Palefsky JM. Pre-vaccination prevalence of anogenital and oral human papillomavirus in young HIV-infected men who have sex with men. Papillomavirus Res 2019; 7:52-61. [PMID: 30658128 PMCID: PMC6356116 DOI: 10.1016/j.pvr.2019.01.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Revised: 12/06/2018] [Accepted: 01/10/2019] [Indexed: 11/23/2022]
Abstract
The aims of this study were to: 1) determine prevalence of anogenital and oral HPV, 2) determine concordance between HPV at anal, perianal, scrotal/penile, and oral sites; and 3) describe factors associated with anogenital HPV types targeted by the 9-valent vaccine. Data were collected from 2012 to 2015 among men who have sex with men 18-26 years of age enrolled in a vaccine trial (N = 145). Penile/scrotal, perianal, anal, and oral samples were tested for 61 HPV types. Logistic regression was used to identify factors associated with types in the 9-valent vaccine. Participants' mean age was 23.0 years, 55.2% were African-American, and 26.2% were Hispanic; 93% had anal, 40% penile, and 6% oral HPV. Among those with anogenital infection, 18% had HPV16. Concordance was low between anogenital and oral sites. Factors independently associated with a 9-valent vaccine-type HPV were: race (African-American vs. White, OR=2.67, 95% CI=1.11-6.42), current smoking (yes vs. no, OR=2.37, 95% CI=1.03-5.48), and number of recent receptive anal sex partners (2+ vs. 0, OR=3.47, 95% CI=1.16-10.4). Most MSM were not infected with HPV16 or HPV18, suggesting that they may still benefit from HPV vaccination, but anogenital HPV was very common, highlighting the importance of vaccinating men before sexual initiation. CLINICAL TRIAL NUMBER: NCT01209325.
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Affiliation(s)
- Jessica A Kahn
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center and the University of Cincinnati College of Medicine, Cincinnati, OH, USA.
| | - Marvin Belzer
- Department of Pediatrics, University of Southern California, Los Angeles, CA, USA.
| | - Xiaofei Chi
- Department of Biostatistics, University of Arkansas for Medical Sciences, Little Rock, AR, USA.
| | - Jeannette Lee
- Department of Biostatistics, University of Arkansas for Medical Sciences, Little Rock, AR, USA.
| | - Aditya H Gaur
- Department of Infectious Diseases, St. Jude Children's Research Hospital, Memphis, TN, USA.
| | - Kenneth Mayer
- Harvard T.H. Chan School of Public Health, Boston, MA, USA.
| | - Jaime Martinez
- John H. Stroger, Jr. Hospital of Cook County, Chicago, IL, USA.
| | | | | | - Mary E Paul
- Baylor College of Medicine, Houston, TX, USA.
| | | | - Daniel Reirden
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA.
| | | | - Ana P Ortiz Martinez
- Cancer Control and Population Sciences Program, University of Puerto Rico, San Juan, PR, USA.
| | - Edward R Cachay
- Department of Medicine, Division of Infectious Diseases, University of California San Diego, San Diego, CA, USA.
| | - Luis F Barroso
- Department of Medicine, Wake Forest University Health Sciences, Winston-Salem, NC, USA.
| | - Maria Da Costa
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA.
| | - Craig M Wilson
- Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham, AL, USA.
| | - Joel M Palefsky
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA.
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Felsen UR, Torian LV, Futterman DC, Stafford S, Xia Q, Allan D, Esses D, Cunningham CO, Weiss JM, Zingman BS. An expanded HIV screening strategy in the Emergency Department fails to identify most patients with undiagnosed infection: insights from a blinded serosurvey. AIDS Care 2019; 32:202-208. [PMID: 31146539 DOI: 10.1080/09540121.2019.1619663] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Screening for HIV in Emergency Departments (EDs) is recommended to address the problem of undiagnosed HIV. Serosurveys are an important method for estimating the prevalence of undiagnosed HIV and can provide insight into the effectiveness of an HIV screening strategy. We performed a blinded serosurvey in an ED offering non-targeted HIV screening to determine the proportion of patients with undiagnosed HIV who were diagnosed during their visit. The study was conducted in a high-volume, urban ED and included patients who had blood drawn for clinical purposes and had sufficient remnant specimen to undergo deidentified HIV testing. Among 4752 patients not previously diagnosed with HIV, 1403 (29.5%) were offered HIV screening and 543 (38.7% of those offered) consented. Overall, undiagnosed HIV was present in 12 patients (0.25%): six among those offered screening (0.4%), and six among those not offered screening (0.2%). Among those with undiagnosed HIV, two (16.7%) consented to screening and were diagnosed during their visit. Despite efforts to increase HIV screening, more than 80% of patients with undiagnosed HIV were not tested during their ED visit. Although half of those with undiagnosed HIV were missed because they were not offered screening, the yield was further diminished because a substantial proportion of patients declined screening. To avoid missed opportunities for diagnosis in the ED, strategies to further improve implementation of HIV screening and optimize rates of consent are needed.
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Affiliation(s)
- Uriel R Felsen
- Department of Medicine, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY, USA
| | - Lucia V Torian
- HIV Epidemiology and Field Services Program, New York City Department of Health and Mental Hygiene, New York, NY, USA
| | - Donna C Futterman
- Adolescent AIDS Program, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY, USA
| | - Stephen Stafford
- Adolescent AIDS Program, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY, USA
| | - Qiang Xia
- HIV Epidemiology and Field Services Program, New York City Department of Health and Mental Hygiene, New York, NY, USA
| | - David Allan
- Department of Emergency Medicine, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY, USA
| | - David Esses
- Department of Emergency Medicine, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY, USA
| | - Chinazo O Cunningham
- Department of Medicine, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY, USA
| | - Jeffrey M Weiss
- Department of Medicine, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY, USA
| | - Barry S Zingman
- Department of Medicine, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY, USA
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Hanna DB, Felsen UR, Ginsberg MS, Zingman BS, Beil RS, Futterman DC, Strickler HD, Anastos K. Increased Antiretroviral Therapy Use and Virologic Suppression in the Bronx in the Context of Multiple HIV Prevention Strategies. AIDS Res Hum Retroviruses 2016; 32:955-963. [PMID: 26892622 DOI: 10.1089/aid.2015.0345] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
Multiple population-based HIV prevention strategies from national, state, local, and institutional levels have been implemented in the Bronx, which has one of the highest HIV prevalences in the U.S. We examined changes in antiretroviral therapy (ART) use and associated outcomes between 2007 and 2014 among patients seen at one of >20 outpatient clinics affiliated with the largest Bronx HIV care provider. Among eligible HIV-infected patients age ≥13 years, we examined annual trends in ART use, mean HIV RNA level, and virologic suppression (<200 copies/ml) overall and among prespecified subgroups. In a subset with suppressed HIV RNA at the end of each year, we determined the percentage whose levels remained suppressed within the next year. Regression models assessed disparities in outcomes. Among 7,196 patients (median age 50, 47% Hispanic, 45% black), we identified consistent increases over time in the percent prescribed ART (78% in 2007 to 93% in 2014) and with virologic suppression (58% to 80%), as mean HIV RNA decreased (351 to 73 copies/ml) (all p < .001). Sustained virologic suppression improved markedly beginning in 2011, coinciding with local test-and-treat initiatives and adoption of expanded treatment guidelines. While disparities among population groups were most pronounced for sustained virologic suppression, those aged 13-24 fared relatively poorly for all outcomes examined (e.g., rate ratio 0.57 for virologic suppression, 95% confidence interval 0.52-0.62, vs. age 65+). Population-wide HIV prevention strategies coincided with improvements in virologic suppression among most population groups. However, more attention is needed to address continued disparities in the HIV care continuum among young people.
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Affiliation(s)
- David B. Hanna
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York
| | - Uriel R. Felsen
- Department of Medicine, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, New York
| | - Mindy S. Ginsberg
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York
| | - Barry S. Zingman
- Department of Medicine, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, New York
| | - Robert S. Beil
- Department of Medicine, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, New York
| | - Donna C. Futterman
- Department of Pediatrics, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, New York
| | - Howard D. Strickler
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York
| | - Kathryn Anastos
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York
- Department of Medicine, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, New York
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Henry-Reid LM, O'Connor KG, Klein JD, Cooper E, Flynn P, Futterman DC. Current pediatrician practices in identifying high-risk behaviors of adolescents. Pediatrics 2010; 125:e741-7. [PMID: 20308220 DOI: 10.1542/peds.2009-0271] [Citation(s) in RCA: 90] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE In the United States, 15- to 24-year-olds represent approximately 14% of HIV cases diagnosed in 2006 and almost 50% of the 19 million sexually transmitted infections (STIs) reported annually. This survey assessed pediatricians' practices regarding preventive health care screening, provision of reproductive health services including HIV and STI screening and counseling, and barriers to providing these services. METHODS A random-sample mailed survey of 1626 US members of the American Academy of Pediatrics in 2005.A total of 752 completed questionnaires were returned (46% response rate). Analysis was limited to the 468 pediatricians who provided health supervision visits to patients who were older than 11 years. RESULTS Most pediatricians discussed sexual activity at preventive care visits; similar numbers discuss abstinence (62%), condoms (61%), and STIs (61%) with slightly fewer discussing HIV (54%). Pediatricians occasionally or rarely/never discussed homosexuality/sexual identity (82%). Most (71%) identified adolescents with high-risk behaviors by clinical interviews. Approximately 30% prescribed condoms, 22% distributed condoms, and 19% provided condom demonstrations. Whereas 46% of pediatricians recommended STI tests for all sexually active teens, only 28% recommended HIV testing for this population. Hospital/clinic-based and inner-city practitioners were more likely to prescribe, provide, and demonstrate condoms and recommend HIV/STI tests for sexually active teens. The most frequently identified barrier to HIV and STI prevention counseling was lack of time. CONCLUSIONS Pediatricians believed it is important to deliver reproductive health services, and most addressed adolescent sexual activity at preventive care visits but did not routinely address homosexuality/sexual identity. Counseling and testing practices varied by physician characteristics.
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Affiliation(s)
- Lisa M Henry-Reid
- Stroger Hospital of Cook County, CORE Center, 1st Directory-Office, Administration Bldg, Room 1111, 1900 W Polk St, Chicago, IL 60612-3834, USA.
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Abstract
Adolescence is a time of dramatic physical, emotional, cognitive, and social change that brings new vulnerabilities. Youth represent half of all new HIV infections in the United States and the rest of the world. The number of newly infected adolescents who acquire the disease behaviorally and the number of perinatally infected children surviving into adolescence have both contributed to this growth. This article reviews the most recent epidemiology of HIV/AIDS in adolescents, gives guidance on clinical practice, including medical and psychosocial care, and examines prevention issues, including counseling and testing, which are needed to make programs effective for youth.
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Affiliation(s)
- Marina Catallozzi
- Adolescent AIDS Program, Section of Adolescent Medicine, Children's Hospital at Montefiore, Albert Einstein College of Medicine, 111 East 210th Street, Bronx, NY 10467, USA.
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Futterman DC. HIV in adolescents and young adults: half of all new infections in the United States. Top HIV Med 2005; 13:101-5. [PMID: 16170227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
Half of new HIV infections in the United States are in individuals aged 13 to 24 years, accounting for 20,000 new infections annually, or 1 every hour. Two thirds of infected youth contract HIV sexually, and more than 60% of new infections are in young women. Approximately 75% of infected youth are in racial or ethnic minority groups. More than one third of HIV-infected young people have not been tested for HIV infection, and the majority of homosexual HIV-infected youth are unaware of their infection status. Increased efforts are needed in comprehensive sex education, including safer sex practices, bringing young people into health care networks, increasing health care provider awareness of risk, and extending counseling and testing to young people. This article summarizes a presentation by Donna Futterman, MD, at the 7th Annual Clinical Conference for Ryan White CARE Act Title I, II, III, and IV Grantees, held in August 2004 in Washington, DC.
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Affiliation(s)
- Donna C Futterman
- Adolescent AIDS Program, Albert Einstein College of Medicine, Bronx, NY, USA
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Abstract
HIV infection in adolescents continues to challenge health providers, policymakers, and advocates for youth. There will be no relief from its complexities soon. Primary care providers are in a unique position to use effective HIV prevention and care interventions. Successful programs move beyond moralism to realism. They show a willingness to engage young people and their families in a sensitive dialogue about the needs of youthful sexual development. Youth at high risk for HIV should be identified and referred to comprehensive care and counseling as soon as possible. HIV-positive youth need intensive individual and group interventions to remain healthy and reduce transmission to others. To protect their patient population, health care providers will need to commit time and effort to making adolescents services visible, flexible, affordable, confidential, culturally appropriate, and universally available.
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Affiliation(s)
- Donna C Futterman
- Adolescent AIDS Program, Albert Einstein College of Medicine, Montefiore Medical Center, 111 East 210th Street, Bronx, NY 10467, USA.
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Wilson CM, Ellenberg JH, Sawyer MK, Belzer M, Crowley-Nowick PA, Puga A, Futterman DC, Peralta L. Serologic response to hepatitis B vaccine in HIV infected and high-risk HIV uninfected adolescents in the REACH cohort. Reaching for Excellence in Adolescent Care and Health. J Adolesc Health 2001; 29:123-9. [PMID: 11530313 DOI: 10.1016/s1054-139x(01)00278-6] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
PURPOSE To evaluate hepatitis B (HBV) vaccine response rates in HIV infected and high-risk HIV uninfected youth and examine associations with responsiveness in the HIV infected group. METHODS Cohorts within the Reaching for Excellence in Adolescent Care and Health (REACH) study population were defined based on receipt of HBV vaccine both retrospectively and prospectively. Sero-responsiveness was determined by HBsAb measurements. Testing was done for HBsAg, HBsAb, and HBcAb. For HBsAb, a value of > 10 International Units per liter was considered a positive response, and the data were collected as either positive or negative from each of the reporting laboratories. Covariates of responsiveness were explored in univariate and multivariate models for each cohort. RESULTS Sixty-one subjects had received a three-dose vaccination course at the time of entry into REACH. HIV uninfected subjects had significantly higher rates of response by serology compared with HIV infected subjects (70% vs. 41.1%; chi(2) = .05; RR = .586, 95% CI: .36-.96). By the time of an annual visit 43 subjects had received three vaccinations with at least one occurring in the study period. The rates of response were similar for the HIV infected and uninfected groups (37.1% vs. 37.5%) in this cohort. Univariate and multivariate analysis in the prospective HIV infected group (N = 35) found an association between elevated CD8(+)/CD38(+)/HLA-DR(+) T cells and lack of HBV vaccine responsiveness (6.7% vs. 60%; chi(2) = .03; RR = .12, 95% CI: .02- .55). CONCLUSIONS The poor HBV vaccine response rate in the HIV uninfected high-risk adolescents was unexpected and suggests that HBV vaccination doses have not been optimized for older adolescents. This is the first report of decreased responsiveness in HIV infected subjects being associated with elevated CD8(+)/CD38(+)/HLA(-)DR(+) T cells and suggests that ongoing viral replication and concomitant immune system activation decreases the ability of the immune system in HIV infected subjects to respond to vaccination.
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Affiliation(s)
- C M Wilson
- University of Alabama at Birmingham, Geographic Medicine, Birmingham, Alabama 35294-2170, USA.
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Futterman DC, Peralta L, Rudy BJ, Wolfson S, Guttmacher S, Rogers AS. The ACCESS (Adolescents Connected to Care, Evaluation, and Special Services) project: social marketing to promote HIV testing to adolescents, methods and first year results from a six city campaign. J Adolesc Health 2001; 29:19-29. [PMID: 11530300 DOI: 10.1016/s1054-139x(01)00290-7] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- D C Futterman
- Department of Pediatrics, Children's Hospital at Montefiore, Albert Einstein College of Medicine, New York, New York, USA
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Wilson CM, Houser J, Partlow C, Rudy BJ, Futterman DC, Friedman LB. The REACH (Reaching for Excellence in Adolescent Care and Health) project: study design, methods, and population profile. J Adolesc Health 2001; 29:8-18. [PMID: 11530299 DOI: 10.1016/s1054-139x(01)00291-9] [Citation(s) in RCA: 83] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Affiliation(s)
- C M Wilson
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama 35294-2170, USA.
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Rogers AS, Lindsey JC, Futterman DC, Zimmer B, Abdalian SE, D'Angelo LJ. Serologic examination of hepatitis B infection and immunization in HIV-positive youth and associated risks. The Pediatric AIDS Clinical Trials Group Protocol 220 Team. AIDS Patient Care STDS 2000; 14:651-7. [PMID: 11119432 DOI: 10.1089/10872910050206577] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
This seroprevalence report examines serologic evidence of hepatitis B immunization or infection and associated demographic/behavioral factors in adolescent (aged 12-20) subjects enrolled in a nontherapeutic clinical trial at 43 Pediatric AIDS Clinical Trials Group (PACTG) clinical centers. Subjects (n = 94) infected with the human immunodeficiency virus (HIV) through sexual activity were categorized as hepatitis B virus (HBV)-immunized, HBV-infected, or nonimmune by hepatitis B serology performed on specimens collected within the subject's first 48 weeks on study (1993-1995). Sixteen percent of the 94 serologically classified subjects were immunized; 19% HBV-infected; 65% nonimmune. Of the three risk factor scores examined (sociodemographic, sexual, and substance abuse), substance use alone demonstrated a significant difference among groups (despite virtually no reported injecting drug behavior), with the sexual risk score exhibiting marginally significant differences. Logistic regression analysis (restricted to nonimmunized subjects) showed that male-male sexual activity raised the odds of HBV infection by a factor of 5.14 (95% confidence interval [CI]: 1.45-18. 23) relative to heterosexual activity; and that for every one point increase on the substance abuse risk scale the odds of infection increased 5% (95% CI: 0.99-1.10). The HBV infection rate in PACTG 220 HIV-positive females is twice United States population-based rates; the rate in PACTG 220 HIV-positive males is nearly seven times higher. Past immunization efforts in this population appear to have been based on sexual activity volume without regard to injecting-drug use in sex partners.
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Affiliation(s)
- A S Rogers
- Pediatric, Adolescent, and Maternal AIDS Branch, National Institute of Child Health and Human Development, NIH, Bethesda, Maryland 20892-7510, USA.
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Holland CA, Ellenberg JH, Wilson CM, Douglas SD, Futterman DC, Kingsley LA, Moscicki AB. Relationship of CD4+ T cell counts and HIV type 1 viral loads in untreated, infected adolescents. Adolescent Medicine HIV/AIDS Research Network. AIDS Res Hum Retroviruses 2000; 16:959-63. [PMID: 10890357 DOI: 10.1089/08892220050058371] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
The REACH Project (Reaching for Excellence in Adolescent Care and Health) of the Adolescent Medicine HIV/AIDS Research Network was designed as a study of an adolescent cohort composed of HIV-1-infected and -uninfected subjects. The goal of the analysis presented was to examine the relationship of CD4+ T cell counts and HIV-1 plasma viral loads in adolescents. The CD4+ T cell counts of 84 HIV+ subjects who were 13 to 19 years of age were measured at the clinical sites, using ACTG standardized techniques. HIV-1 viral loads in frozen plasma were determined by the NASBA/NucliSens assay at a central laboratory. Past and current treatment with antiretroviral drugs was determined by medical record abstraction and interview data. The slope of the line generated by regressing log10 HIV-1 RNA (copies/ml) versus CD4+ T cell counts of REACH subjects who are antiretroviral drug naive was negative and significantly different than zero. A negative association has also been reported for antiretroviral drug-naive, adult males in the Pittsburgh Men's Study, a component of MACS (Pitt-MACS) (Mellors J, et al.: Science 1996;272:1167). These data show that in adolescents, as in adults, HIV-1 RNA concentrations are correlated with corresponding absolute CD4+ T cell count. The slopes of the lines generated with data from each cohort were different (p = 0.003). In addition to age, there are sex and racial differences in the makeup of the two cohorts. Any or all of these differences may affect the slopes of the lines.
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Affiliation(s)
- C A Holland
- Center for Virology Immunology and Infectious Disease Research, Children's Research Institute, Children's National Medical Center, Washington, DC 20010, USA.
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