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Falade-Nwulia O, Lesko CR, Fojo AT, Keruly JC, Moore RD, Sutcliffe CG, Mehta SH, Chander G, Thomas DL, Sulkowski M. Hepatitis C Treatment in People With HIV: Potential to Eliminate Disease and Disparity. J Infect Dis 2024; 229:775-779. [PMID: 37793170 PMCID: PMC10938212 DOI: 10.1093/infdis/jiad433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2023] [Revised: 09/20/2023] [Accepted: 10/02/2023] [Indexed: 10/06/2023] Open
Abstract
Access to direct acting antivirals (DAAs) may be associated with reductions in hepatitis C virus (HCV) viremia prevalence among people with human immunodeficiency virus (PWH). Among 3755 PWH, estimated HCV viremia prevalence decreased by 94.0% from 36% (95% confidence interval [CI], 27%-46%) in 2009 (pre-DAA era) to 2% (95% CI, 0%-4%) in 2021 (DAA era). Male sex, black race, and older age were associated with HCV viremia in 2009 but not in 2021. Injection drug use remained associated with HCV viremia in 2009 and 2021. Targeted interventions are needed to meet the HCV care needs of PWH who use drugs.
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Affiliation(s)
- Oluwaseun Falade-Nwulia
- Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Catherine R Lesko
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Anthony T Fojo
- Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jeanne C Keruly
- Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Richard D Moore
- Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Catherine G Sutcliffe
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Shruti H Mehta
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Geetanjali Chander
- Division of General Internal Medicine, University of Washington, Seattle, Washington, USA
| | - David L Thomas
- Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Mark Sulkowski
- Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Markowski MC, Pirsl F, Keruly JC, Chander G, Moore RD, Lau B, Joshu CE. Clinical management and outcomes of HIV-positive patients newly diagnosed with prostate cancer: a single institution experience. Prostate Cancer Prostatic Dis 2024; 27:144-146. [PMID: 36057651 PMCID: PMC9981812 DOI: 10.1038/s41391-022-00586-7] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2022] [Revised: 08/05/2022] [Accepted: 08/18/2022] [Indexed: 01/28/2023]
Abstract
INTRODUCTION 10-year outcomes in patients living with HIV who are diagnosed with prostate cancer are unknown. METHODS 52 patients living with HIV were diagnosed with prostate cancer. Disease-free survival stratified by clinical, pathologic, and HIV characteristics were examined. RESULTS No difference in disease-free survival was observed based on prostate cancer treatment modality, CD4 count, or HIV viral load. CONCLUSIONS Prostate cancer outcomes in patients living with HIV are favorable irrespective of treatment modality.
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Affiliation(s)
- Mark C Markowski
- Department of Oncology, Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD, USA.
| | - Filip Pirsl
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Jeanne C Keruly
- Department of Medicine, Division of Infectious Disease, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Geetanjali Chander
- Department of Medicine, Division of General Internal Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Richard D Moore
- Department of Medicine, Division of General Internal Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Bryan Lau
- Department of Oncology, Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD, USA
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Department of Medicine, Division of General Internal Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Corinne E Joshu
- Department of Oncology, Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD, USA
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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Tang X, Schalet BD, Janulis P, Keruly JC, Moore RD, Milloy MJ, DeBeck K, Hayashi K, Javanbakht M, Kim S, Siminski S, Shoptaw S, Gorbach PM. Evaluating the agreement between different substance use recall periods in multiple HIV cohorts. Drug Alcohol Depend 2024; 254:111043. [PMID: 38061201 PMCID: PMC10872532 DOI: 10.1016/j.drugalcdep.2023.111043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 11/23/2023] [Accepted: 11/25/2023] [Indexed: 01/08/2024]
Abstract
BACKGROUND This study aims to evaluate the agreement in substance use on both binary and ordinal scales between 3-month and 6-month recall periods with samples from different communities, demographic backgrounds, and HIV status. METHODS We administered the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) to 799 participants from three different North American cohorts focused on substance use and HIV. We conducted a within-person agreement analysis by calculating the agreement levels and Kappa statistic between data collected using the 3-month recall ASSIST and 6-month custom substance use surveys as well as different terminology for each substance in multiple cohorts. RESULTS For all drugs studied, the agreement on the binary use or ordinal frequency of use metrics showed a high agreement level between 80.4% and 97.9% and an adequate adjusted kappa value between 0.61 and 0.96, suggesting substantial agreement. According to the agreement criteria we proposed, substance use data collected using different recall periods and with variation in drug names can be harmonized across cohorts. CONCLUSIONS This study is the first to evaluate the feasibility of data harmonization of substance use by demonstrating high level of agreement between different recall periods in different cohorts. The results can inform data harmonization efforts in consortia where data are collected from cohorts using different questions and recall periods.
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Affiliation(s)
- Xiaodan Tang
- Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
| | - Benjamin D Schalet
- Department of Epidemiology and Data Science, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Patrick Janulis
- Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL, USA; Institute for Sexual and Gender Minority Health and Wellbeing, Northwestern University, Chicago IL, USA
| | - Jeanne C Keruly
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Richard D Moore
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - M-J Milloy
- Department of Medicine, University of British Columbia, Vancouver, Canada; British Columbia Centre on Substance Use, Vancouver, Canada
| | - Kora DeBeck
- British Columbia Centre on Substance Use, Vancouver, Canada; School of Public Policy, Simon Fraser University, Vancouver Canada
| | - Kanna Hayashi
- British Columbia Centre on Substance Use, Vancouver, Canada; Faculty of Health Sciences, Simon Fraser University, Vancouver Canada
| | - Marjan Javanbakht
- Department of Epidemiology, Fielding School of Public Health, University of California Los Angeles, Los Angeles, CA, USA
| | - Soyeon Kim
- Frontier Science Foundation, Boston, MA, USA
| | | | - Steven Shoptaw
- Department of Family Medicine, Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, USA
| | - Pamina M Gorbach
- Department of Epidemiology, Fielding School of Public Health, University of California Los Angeles, Los Angeles, CA, USA
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Garneau WM, Jones JL, Dashler GM, Mostafa HH, Judson SD, Kwon N, Hamill MM, Gilliams EA, Rudolph DS, Keruly JC, Fall A, Klein EY, Hansoti B, Gebo KA. Risk Factors for Hospitalization and Effect of Immunosuppression on Clinical Outcomes Among an Urban Cohort of Patients With Mpox. Open Forum Infect Dis 2023; 10:ofad533. [PMID: 38058459 PMCID: PMC10697423 DOI: 10.1093/ofid/ofad533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 10/30/2023] [Indexed: 12/08/2023] Open
Abstract
Background During the 2022 mpox outbreak most patients were managed as outpatients, but some required hospitalization. Uncontrolled human immunodeficiency virus (HIV) has been identified as a risk factor for severe mpox. Methods Patients with mpox diagnosed or treated within the Johns Hopkins Health System between 1 June and 15 December 2022 were included. The primary outcome of interest was risk of hospitalization. Demographic features, comorbid conditions, treatment, and clinical outcomes were determined. Results A total of 353 patients were tested or treated for mpox; 100 had mpox diagnosed or treated (median age, 35.3 years; 97.0% male; 57.0% black and 10.0% Hispanic; 46.0% people with HIV [PWH]). Seventeen patients (17.0%) required hospitalization, 10 of whom were PWH. Age >40 years, race, ethnicity, HIV status, insurance status, and body mass index >30 (calculated as weight in kilograms divided by height in meters squared) were not associated with hospitalization. Eight of 9 patients (88.9%) with immunosuppression were hospitalized. Immunosuppression was associated with hospitalization in univariate (odds ratio, 69.3 [95% confidence interval, 7.8-619.7]) and adjusted analysis (adjusted odds ratio, 94.8 [8.5-1060.1]). Two patients (11.8%) who were hospitalized required intensive care unit admission and died; both had uncontrolled HIV infection and CD4 T-cell counts <50/µL. Median cycle threshold values for the first positive mpox virus sample did not differ between those who were hospitalized and those who were not. Conclusions Immunosuppression was a significant risk factor for hospitalization with mpox. PWH with CD4 T-cell counts <50/µL are at high risk of death due to mpox infection. Patients who are immunosuppressed should be considered for early and aggressive treatment of mpox, given the increased risk of hospitalization.
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Affiliation(s)
- William M Garneau
- Department of Medicine, Division of Hospital Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Joyce L Jones
- Departent of Medicine, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Gabriella M Dashler
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Heba H Mostafa
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Seth D Judson
- Departent of Medicine, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Nathan Kwon
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Matthew M Hamill
- Departent of Medicine, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Elizabeth A Gilliams
- Departent of Medicine, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - David S Rudolph
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jeanne C Keruly
- Departent of Medicine, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Amary Fall
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Eili Y Klein
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Bhakti Hansoti
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Kelly A Gebo
- Departent of Medicine, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Lesko CR, Falade-Nwulia OO, Pytell JD, Hutton HE, Fojo AT, Keruly JC, Moore RD, Chander G. Joint effects of substance use disorders and recent substance use on HIV viral non-suppression among people engaged in HIV care in an urban clinic, 2014-2019. Addiction 2023; 118:2193-2202. [PMID: 37491566 PMCID: PMC10592031 DOI: 10.1111/add.16301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Accepted: 06/19/2023] [Indexed: 07/27/2023]
Abstract
AIMS To estimate the joint effects of substance use disorder (SUD) and recent substance use on human immunodeficiency virus (HIV) non-suppression. DESIGN Retrospective clinical cohort study with repeated observations within individuals. SETTING Baltimore, Maryland, United States. PARTICIPANTS 1881 patients contributed 10 794 observations. MEASUREMENTS The primary independent variable was the combination of history of SUD and recent substance use. History of SUD was defined as any prior International Classification of Diseases 9/10 code for cocaine or opioid disorder. Recent substance use was defined as the self-report of cocaine or non-prescribed opioid use on the National Institute of Drug Abuse-modified Alcohol, Smoking and Substance Involvement Screening Test or clinician-documented cocaine or opioid use abstracted from the medical record. The outcome was viral non-suppression, defined as HIV RNA >200 copies/mL on the first viral load measurement within 1 year subsequent to each observation of substance use. We adjusted for birth sex, Black race, age, HIV acquisition risk factors, years in care and CD4 cell count. In secondary analyses, we also adjusted for depressive, anxiety and panic symptoms, cannabis use and cannabis use disorder. FINDINGS On their first observation, 31% of patients had a history of an SUD and 18% had recent substance use. Relative to no history of SUD and no recent substance use, the 1-year fully adjusted risk difference (RD) for viral non-suppression associated with cocaine and opioid use disorder and recent substance use was 7.7% (95% CI = 5.3%-10.0%), the RD was 5.5% (95% CI = 1.2%-9.7%) for history of cocaine use disorder without recent substance use, and the RD was 4.6% (95% CI = 2.7%-6.5%) for recent substance use without a SUD. CONCLUSIONS Substance use and substance use disorders appear to be highly prevalent among, and independently associated with, viral non-suppression among people with HIV.
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Affiliation(s)
- Catherine R Lesko
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | | | - Jarratt D Pytell
- University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Heidi E Hutton
- Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Anthony T Fojo
- Johns Hopkins School of Medicine, Baltimore, Maryland, USA
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Pytell JD, Fojo AT, Keruly JC, Snow LN, Falade-Nwulia O, Moore RD, Chander G, Lesko CR. Measuring time in buprenorphine treatment stages among people with HIV and opioid use disorder by retention definition and its association with cocaine and hazardous alcohol use. Addict Sci Clin Pract 2023; 18:51. [PMID: 37660116 PMCID: PMC10474763 DOI: 10.1186/s13722-023-00408-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Accepted: 08/23/2023] [Indexed: 09/04/2023] Open
Abstract
BACKGROUND We use a novel, longitudinal approach to describe average time spent in opioid use disorder (OUD) cascade of care stages for people with HIV (PWH) and with OUD, incorporating four definitions of treatment retention. Using this approach, we describe the impact of cocaine or hazardous alcohol use on time spent retained on buprenorphine. METHODS We followed PWH with OUD enrolled in the Johns Hopkins HIV Clinical Cohort from their first buprenorphine treatment episode between 2013 and 2020. We estimated 4-year restricted mean time spent on buprenorphine below buprenorphine retention threshold, on buprenorphine above retention threshold, off buprenorphine and in HIV care, loss to follow-up, and death. Retention definitions were based on retention threshold (180 vs 90 days) and allowable treatment gap (7 vs 30 days). Differences in 2-year restricted mean time spent retained on buprenorphine were estimated for patients with and without cocaine or hazardous alcohol use. RESULTS The study sample (N = 179) was 63% male, 82% non-Hispanic Black, and mean age was 53 (SD 8) years. Patients spent on average 13.9 months (95% CI 11.4, 16.4) on buprenorphine over 4 years. There were differences in time spent retained on buprenorphine based on the retention definition, ranging from 6.5 months (95% CI 4.6, 8.5) to 9.6 months (95% CI 7.4, 11.8). Patients with cocaine use spent fewer months retained on buprenorphine. There were no differences for patients with hazardous alcohol use. CONCLUSIONS PWH with OUD spend relatively little time receiving buprenorphine in their HIV primary care clinic. Concurrent cocaine use at buprenorphine initiation negatively impact time on buprenorphine.
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Affiliation(s)
- Jarratt D Pytell
- Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Mail Stop B180, 12631 E. 17Th Ave, Aurora, CO, 80045, USA.
| | - Anthony T Fojo
- Division of General Internal Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Jeanne C Keruly
- Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - LaQuita N Snow
- Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Oluwaseun Falade-Nwulia
- Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Richard D Moore
- Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Geetanjali Chander
- Division of General Internal Medicine, University of Washington School of Medicine, Seattle, WA, USA
| | - Catherine R Lesko
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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7
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Crothers K, Nance RM, Whitney BM, Harding BN, Heckbert SR, Budoff MJ, Mathews WC, Bamford L, Cachay ER, Eron JJ, Napravnik S, Moore RD, Keruly JC, Willig A, Burkholder G, Feinstein MJ, Saag MS, Kitahata MM, Crane HM, Delaney JAC. Chronic obstructive pulmonary disease and the risk for myocardial infarction by type in people with HIV. AIDS 2023; 37:745-752. [PMID: 36728918 PMCID: PMC10041661 DOI: 10.1097/qad.0000000000003465] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVES The relationship between chronic obstructive pulmonary disease (COPD) and cardiovascular disease in people with HIV (PWH) is incompletely understood. We determined whether COPD is associated with risk of myocardial infarction (MI) among PWH, and if this differs for type 1 (T1MI) and type 2 (T2MI). DESIGN We utilized data from five sites in the Centers for AIDS Research Network of Integrated Clinical Systems (CNICS) cohort, a multisite observational study. METHODS Our primary outcome was an adjudicated MI, classified as T1MI or T2MI. We defined COPD based on a validated algorithm requiring COPD diagnosis codes and at least 90-day continuous supply of inhalers. We conducted time-to-event analyses to first MI and used multivariable Cox proportional hazards models to measure associations between COPD and MI. RESULTS Among 12 046 PWH, 945 had COPD. Overall, 309 PWH had an MI: 58% had T1MI ( N = 178) and 42% T2MI ( N = 131). In adjusted models, COPD was associated with a significantly increased risk of all MI [adjusted hazard ratio (aHR) 2.68 (95% confidence interval (CI) 1.99-3.60)] even after including self-reported smoking [aHR 2.40 (95% CI 1.76-3.26)]. COPD was also associated with significantly increased risk of T1MI and T2MI individually, and with sepsis and non-sepsis causes of T2MI. Associations were generally minimally changed adjusting for substance use. CONCLUSION COPD is associated with a substantially increased risk for MI, including both T1MI and T2MI, among PWH. Given the association with both T1MI and T2MI, diverse mechanistic pathways are involved. Future strategies to decrease risk of T1MI and T2MI in PWH who have COPD are needed.
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Affiliation(s)
| | - Robin M Nance
- Department of Medicine
- Department of Epidemiology, University of Washington, Seattle, Washington, USA
| | | | - Barbara N Harding
- Barcelona Institute of Global Health (ISGlobal) and Universitat Pompeu Fabra (UPF), Barcelona
- CIBER Epidemiolog ia y Salud Publica (CIBERESP), Madrid, Spain
| | - Susan R Heckbert
- Department of Epidemiology, University of Washington, Seattle, Washington, USA
| | - Matthew J Budoff
- Lundquist Institute at Harbor-University of California, Los Angeles (UCLA), Torrance
| | - William C Mathews
- Department of Medicine, University of California San Diego, California
| | - Laura Bamford
- Department of Medicine, University of California San Diego, California
| | - Edward R Cachay
- Department of Medicine, University of California San Diego, California
| | - Joseph J Eron
- University of North Carolina, Chapel Hill, North Carolina
| | | | - Richard D Moore
- Johns Hopkins School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Jeanne C Keruly
- Johns Hopkins School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Amanda Willig
- Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Greer Burkholder
- Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Matthew J Feinstein
- Department of Medicine, Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Michael S Saag
- Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | | | | | - Joseph A C Delaney
- Department of Epidemiology, University of Washington, Seattle, Washington, USA
- College of Pharmacy, University of Manitoba, Winnipeg, Manitoba, Canada
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8
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El-Nahal WG, Chander G, Jones JL, Fojo AT, Keruly JC, Manabe YC, Moore RD, Gebo KA, Lesko CR. Telemedicine Use Among People With HIV in 2021: The Hybrid-Care Environment. J Acquir Immune Defic Syndr 2023; 92:223-230. [PMID: 36730830 PMCID: PMC9969325 DOI: 10.1097/qai.0000000000003124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Accepted: 10/24/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND Telemedicine use for the care of people with HIV (PWH) significantly expanded during the COVID-19 pandemic. During 2021, vaccine uptake increased and patients were encouraged to resume in-person care, resulting in a mixture of in-person and telemedicine visits. We studied how different patient populations used telemedicine in this hybrid-care environment. METHODS Using observational data from patients enrolled in the Johns Hopkins HIV Clinical Cohort, we analyzed all in-person and telemedicine HIV primary care visits completed in an HIV clinic from January 1st, 2021, to December 31st, 2021. We used log-binomial regression to investigate the association between patient characteristics and the probability of completing a telemedicine versus in-person visit and the probability of completing a video versus telephone visit. RESULTS A total of 5518 visits were completed by 1884 patients; 4282 (77.6%) visits were in-person, 800 (14.5%) by phone, and 436 (7.9%) by video. The relative risk (RR) of completing telemedicine vs. in-person visits was 0.65 (95% Confidence Interval (CI): 0.47, 0.91) for patients age 65 years or older vs. age 20-39 years; 0.84 (95% CI: 0.72, 0.98) for male patients vs. female patients; 0.81 (95% CI: 0.66, 0.99) for Black vs. White patients; 0.62 (95% CI: 0.49, 0.79) for patients in the highest vs. lowest quartile of Area Deprivation Index; and 1.52 (95% CI: 1.26, 1.84) for patients >15 miles vs. <5 miles from clinic. CONCLUSIONS In the second year of the pandemic, overall in-person care was used more than telemedicine and significant differences persist across subgroups in telemedicine uptake.
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Affiliation(s)
- Walid G. El-Nahal
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Geetanjali Chander
- Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA
| | - Joyce L. Jones
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Anthony T. Fojo
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jeanne C. Keruly
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Yukari C. Manabe
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Richard D. Moore
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Kelly A. Gebo
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Catherine R. Lesko
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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9
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Drumright LN, Nance RM, Ruderman SA, Ma J, Whitney BM, Hahn A, Fredericksen RJ, Luu B, Lober WB, Moore RD, Budoff MJ, Keruly JC, Christopoulos K, Puryear S, Willig A, Cropsey K, Mathews WC, Cachay E, Bamford L, Eron JJ, Napravnik S, Mayer KH, O'Cleirigh C, Mccaul ME, Chander G, Feinstein MJ, Saag MS, Kitahata MM, Heckbert SR, Crane HM, Delaney JAC. Associations between alcohol and cigarette use and type 1 and 2 myocardial infarction among people with HIV. HIV Med 2023. [PMID: 36855253 DOI: 10.1111/hiv.13466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Accepted: 01/19/2023] [Indexed: 03/02/2023]
Abstract
OBJECTIVES People with HIV have a higher risk of myocardial infarction (MI) than the general population, with a greater proportion of type 2 MI (T2MI) due to oxygen demand-supply mismatch compared with type 1 (T1MI) resulting from atherothrombotic plaque disruption. People living with HIV report a greater prevalence of cigarette and alcohol use than do the general population. Alcohol use and smoking as risk factors for MI by type are not well studied among people living with HIV. We examined longitudinal associations between smoking and alcohol use patterns and MI by type among people living with HIV. DESIGN AND METHODS Using longitudinal data from the Centers for AIDS Research Network of Integrated Clinical Systems cohort, we conducted time-updated Cox proportional hazards models to determine the impact of smoking and alcohol consumption on adjudicated T1MI and T2MI. RESULTS Among 13 506 people living with HIV, with a median 4 years of follow-up, we observed 177 T1MI and 141 T2MI. Current smoking was associated with a 60% increase in risk of both T1MI and T2MI. In addition, every cigarette smoked per day was associated with a 4% increase in risk of T1MI, with a suggestive, but not significant, 2% increase for T2MI. Cigarette use had a greater impact on T1MI for men than for women and on T2MI for women than for men. Increasing alcohol use was associated with a lower risk of T1MI but not T2MI. Frequency of heavy episodic alcohol use was not associated with MI. CONCLUSIONS Our findings reinforce the prioritization of smoking reduction, even without cessation, and cessation among people living with HIV for MI prevention and highlight the different impacts on MI type by gender.
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Affiliation(s)
- Lydia N Drumright
- University of Washington, Seattle, Washington, USA.,University of Cambridge, Cambridge, UK
| | | | | | - Jimmy Ma
- University of Washington, Seattle, Washington, USA
| | | | - Andrew Hahn
- University of Washington, Seattle, Washington, USA
| | | | - Brandon Luu
- Northern Ontario School of Medicine, Thunder Bay, Ontario, Canada
| | | | | | | | | | | | - Sarah Puryear
- University of California, San Francisco, California, USA
| | | | | | | | - Edward Cachay
- University of California, San Diego, California, USA
| | - Laura Bamford
- University of California, San Diego, California, USA
| | - Joseph J Eron
- University of North Carolina, Chapel Hill, North Carolina, USA
| | - Sonia Napravnik
- University of North Carolina, Chapel Hill, North Carolina, USA
| | | | | | | | - Geetanjali Chander
- University of Washington, Seattle, Washington, USA.,Johns Hopkins University, Baltimore, Maryland, USA
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10
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Pytell JD, Shen NM, Keruly JC, Lesko CR, Lau B, Fojo AT, Baum MK, Gorbach PM, Javanbakht M, Kipke M, Kirk GD, Mustanski B, Shoptaw S, Siminski S, Moore RD, Chander G. The relationship of alcohol and other drug use during the COVID-19 pandemic among people with or at risk of HIV; A cross-sectional survey of people enrolled in Collaborating Consortium of Cohorts Producing NIDA Opportunities (C3PNO) cohorts. Drug Alcohol Depend 2022; 241:109382. [PMID: 35331580 PMCID: PMC8891146 DOI: 10.1016/j.drugalcdep.2022.109382] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Revised: 02/15/2022] [Accepted: 02/26/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND Alcohol use during the COVID-19 pandemic increased. People living with HIV or at risk for HIV acquisition often have psycho-social and structural barriers or co-occurring substance use making them vulnerable to the adverse effects of alcohol. We describe factors associated with alcohol use during the COVID-19 pandemic in this group. METHODS From May 2020 to February 2021, 1984 people enrolled in 6 existing cohort studies completed surveys about alcohol and other drug use during the COVID-19 pandemic. We describe the past-month prevalence of no alcohol use, low-risk use, and hazardous use. We use multinomial regression to describe factors associated with low-risk or hazardous alcohol use relative to no alcohol use. RESULTS Forty-five percent of participants reported no alcohol use, 33% low-risk use, and 22% hazardous use in the past 30 days. Cannabis and stimulant use were associated with a higher prevalence of low-risk use relative to no use. Tobacco, stimulant, cannabis use and recent overdose were associated with a higher prevalence of hazardous use relative to no use. Substance use treatment and living with HIV were associated with a lower prevalence of low-risk or hazardous use relative to no use. CONCLUSIONS Stimulant use was strongly associated with a higher prevalence of hazardous alcohol use while engagement in substance use treatment or living with HIV was associated with a lower prevalence. Ascertaining hazardous alcohol and other drug use, particularly stimulants, in clinical care could identify people at higher risk for adverse outcome and harm reduction counseling.
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Affiliation(s)
- Jarratt D Pytell
- Department of Medicine, Johns Hopkins School of Medicine, 600 N. Wolfe St., Baltimore, MD 21287, USA.
| | - Nicola M Shen
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe St., Baltimore, MD 21205, USA
| | - Jeanne C Keruly
- Division of Infectious Diseases, Johns Hopkins School of Medicine, 600 N. Wolfe St., Baltimore, MD 21287, USA
| | - Catherine R Lesko
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe St., Baltimore, MD 21205, USA
| | - Bryan Lau
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe St., Baltimore, MD 21205, USA
| | - Anthony T Fojo
- Department of Medicine, Johns Hopkins School of Medicine, 600 N. Wolfe St., Baltimore, MD 21287, USA
| | - Marianna K Baum
- Department of Dietetics and Nutrition, Robert Stempel College of Public Health, Florida International University, 11200 SW 8 Street, AHC-5, 326, Miami, FL 33199, USA
| | - Pamina M Gorbach
- Department of Epidemiology, Fielding School of Public Health, University of California Los Angeles, Box 951772, CHS 41-295, Los Angeles, CA 90095-1772, USA
| | - Marjan Javanbakht
- Department of Epidemiology, Fielding School of Public Health, University of California Los Angeles, Box 951772, CHS 41-295, Los Angeles, CA 90095-1772, USA
| | - Michele Kipke
- University of Southern California, Children's Hospital Los Angeles, CHL 4650 W. Sunset Blvd., Los Angeles, CA 90027, USA
| | - Gregory D Kirk
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe St., Baltimore, MD 21205, USA
| | - Brian Mustanski
- Institute for Sexual and Gender Minority Health and Wellbeing and Department of Medical Social Sciences, Northwestern University, Chicago, IL, USA
| | - Steven Shoptaw
- Department of Family Medicine, University of California Los Angeles, 10880 Wilshire Boulevard, Los Angeles, CA 90024, USA
| | - Susanne Siminski
- Frontier Science Foundation, 4033 Maple Road, Amherst, NY 14226, USA
| | - Richard D Moore
- Department of Medicine, Johns Hopkins School of Medicine, 600 N. Wolfe St., Baltimore, MD 21287, USA
| | - Geetanjali Chander
- Department of Medicine, Johns Hopkins School of Medicine, 600 N. Wolfe St., Baltimore, MD 21287, USA
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11
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Lesko CR, Keruly JC, Moore RD, Shen NM, Pytell JD, Lau B, Fojo AT, Mehta SH, Kipke M, Baum MK, Shoptaw S, Gorbach PM, Mustanski B, Javanbakht M, Siminski S, Chander G. COVID-19 and the HIV continuum in people living with HIV enrolled in Collaborating Consortium of Cohorts Producing NIDA Opportunities (C3PNO) cohorts. Drug Alcohol Depend 2022; 241:109355. [PMID: 35331581 PMCID: PMC8837482 DOI: 10.1016/j.drugalcdep.2022.109355] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Revised: 12/20/2021] [Accepted: 01/10/2022] [Indexed: 01/28/2023]
Abstract
BACKGROUND The COVID-19 pandemic disrupted the normal delivery of HIV care, altered social support networks, and caused economic insecurity. People with HIV (PWH) are vulnerable to such disruptions, particularly if they have a history of substance use. We describe engagement in care and adherence to antiretroviral therapy (ART) for PWH during the pandemic. METHODS From May 2020 to February 2021, 773 PWH enrolled in 6 existing cohorts completed 1495 surveys about substance use and engagement in HIV care during the COVID-19 pandemic. We described the prevalence and correlates of having missed a visit with an HIV provider in the past month and having missed a dose of ART in the past week. RESULTS Thirteen percent of people missed an HIV visit in the past month. Missing a visit was associated with unstable housing, food insecurity, anxiety, low resiliency, disruptions to mental health care, and substance use including cigarette smoking, hazardous alcohol use, cocaine, and cannabis use. Nineteen percent of people reported missing at least one dose of ART in the week prior to their survey. Missing a dose of ART was associated with being a man, low resiliency, disruptions to mental health care, cigarette smoking, hazardous alcohol use, cocaine, and cannabis use, and experiencing disruptions to substance use treatment. CONCLUSIONS Social determinants of health, substance use, and disruptions to mental health and substance use treatment were associated with poorer engagement in HIV care. Close attention to continuity of care during times of social disruption is especially critical for PWH.
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Affiliation(s)
- Catherine R Lesko
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe St., Baltimore, MD 21205, USA.
| | - Jeanne C Keruly
- Division of Infectious Diseases, Johns Hopkins School of Medicine, 1830 E. Monument St., Baltimore, MD 21287, USA
| | - Richard D Moore
- Division of General Internal Medicine, Johns Hopkins School of Medicine, 1830 E. Monument St., Baltimore, MD 21287, USA
| | - Nicola M Shen
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe St., Baltimore, MD 21205, USA
| | - Jarratt D Pytell
- Division of General Internal Medicine, Johns Hopkins School of Medicine, 1830 E. Monument St., Baltimore, MD 21287, USA
| | - Bryan Lau
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe St., Baltimore, MD 21205, USA
| | - Anthony T Fojo
- Division of General Internal Medicine, Johns Hopkins School of Medicine, 1830 E. Monument St., Baltimore, MD 21287, USA
| | - Shruti H Mehta
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe St., Baltimore, MD 21205, USA
| | - Michele Kipke
- University of Southern California, Children's Hospital Los Angeles, CHL 4650 W. Sunset Blvd., Los Angeles, CA 90027, USA
| | - Marianna K Baum
- Department of Dietetics and Nutrition, Roger Stempel College of Public Health, Florida International University, 11200 SW 8 Street, AHC-5, 326, Miami, FL 33199, USA
| | - Steven Shoptaw
- Department of Family Medicine, University of California Los Angeles, 10880 Wilshire Boulevard, Los Angeles, CA 90024, USA
| | - Pamina M Gorbach
- Department of Epidemiology, Fielding School of Public Health, University of California Los Angeles, Box 951772, CHS 41-295, Los Angeles, CA 90095-1772, USA
| | - Brian Mustanski
- Institute for Sexual and Gender Minority Health and Wellbeing and Department of Medical Social Sciences, Northwestern University, 625 N. Michigan Ave, Chicago, IL 60611, USA
| | - Marjan Javanbakht
- Department of Epidemiology, Fielding School of Public Health, University of California Los Angeles, Box 951772, CHS 41-295, Los Angeles, CA 90095-1772, USA
| | - Suzanne Siminski
- Frontier Science Foundation, 4033 Maple Road, Amherst, NY 14226, USA
| | - Geetanjali Chander
- Division of General Internal Medicine, Johns Hopkins School of Medicine, 1830 E. Monument St., Baltimore, MD 21287, USA
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12
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El-Nahal WG, Shen NM, Keruly JC, Jones JL, Fojo AT, Manabe YC, Moore RD, Gebo KA, Chander G, Lesko CR. Time Between Viral Loads for People With HIV During the COVID-19 Pandemic. J Acquir Immune Defic Syndr 2022; 91:109-116. [PMID: 35617019 PMCID: PMC9388538 DOI: 10.1097/qai.0000000000003026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Accepted: 05/16/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND During the COVID-19 pandemic, patients experienced significant care disruptions, including laboratory monitoring. We investigated changes in the time between viral load (VL) checks for people with HIV (PWH) associated with the pandemic. SETTING AND METHODS This was an observational analysis of VLs of PWH in routine care at a large subspecialty clinic. At pandemic onset, the clinic temporarily closed its onsite laboratory. The exposure was time period (time varying): prepandemic (January 1, 2019-March 15, 2020); pandemic laboratory closed (March 16-July 12, 2020); and pandemic laboratory open (July 13-December 31, 2020). We estimated time from an index VL to a subsequent VL, stratified by whether the index VL was suppressed (≤200 copies/mL). We also calculated cumulative incidence of a nonsuppressed VL following a suppressed index VL, and of resuppression following a loss of viral suppression. RESULTS Compared with prepandemic, hazard ratios for next VL check were 0.34 (95% CI: 0.30 to 0.37, laboratory-closed) and 0.73 (CI: 0.68 to 0.78, laboratory-open) for suppressed patients, and 0.56 (CI: 0.42 to 0.79, laboratory-closed) and 0.92 (95% CI: 0.76 to 1.10, laboratory-open) for nonsuppressed patients. The 12-month cumulative incidence of loss of suppression was the same in the pandemic laboratory-open (4%) and prepandemic (4%) period. The hazard of resuppression following the loss of suppression was lower during the pandemic laboratory-open versus the prepandemic period (hazard ratio: 0.68, 95% CI: 0.50 to 0.92). CONCLUSIONS Early pandemic restrictions and laboratory closure significantly delayed VL monitoring. Once the laboratory reopened, nonsuppressed patients resumed normal monitoring. Suppressed patients still had a delay but no significant loss of suppression.
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Affiliation(s)
- Walid G. El-Nahal
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Nicola M. Shen
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Jeanne C. Keruly
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Joyce L. Jones
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Anthony T. Fojo
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Yukari C. Manabe
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Richard D. Moore
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Kelly A. Gebo
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Geetanjali Chander
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Catherine R. Lesko
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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13
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Shapiro AE, Ignacio RAB, Whitney BM, Delaney JA, Nance RM, Bamford L, Wooten D, Keruly JC, Burkholder G, Napravnik S, Mayer KH, Webel AR, Kim HN, Van Rompaey SE, Christopoulos K, Jacobson J, Karris M, Smith D, Johnson MO, Willig A, Eron JJ, Hunt P, Moore RD, Saag MS, Mathews WC, Crane HM, Cachay ER, Kitahata MM. Factors Associated With Severity of COVID-19 Disease in a Multicenter Cohort of People With HIV in the United States, March-December 2020. J Acquir Immune Defic Syndr 2022; 90:369-376. [PMID: 35364600 PMCID: PMC9246864 DOI: 10.1097/qai.0000000000002989] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Accepted: 03/03/2022] [Indexed: 01/19/2023]
Abstract
BACKGROUND Understanding the spectrum of COVID-19 in people with HIV (PWH) is critical to provide clinical guidance and risk reduction strategies. SETTING Centers for AIDS Research Network of Integrated Clinic System, a US multisite clinical cohort of PWH in care. METHODS We identified COVID-19 cases and severity (hospitalization, intensive care, and death) in a large, diverse HIV cohort during March 1, 2020-December 31, 2020. We determined predictors and relative risks of hospitalization among PWH with COVID-19, adjusted for disease risk scores. RESULTS Of 16,056 PWH in care, 649 were diagnosed with COVID-19 between March and December 2020. Case fatality was 2%; 106 (16.3%) were hospitalized, and 12 died. PWH with current CD4 count <350 cells/mm 3 [aRR 2.68; 95% confidence interval (CI): 1.93 to 3.71; P < 0.001] or lowest recorded CD4 count <200 cells/mm 3 (aRR 1.67; 95% CI: 1.18 to 2.36; P < 0.005) had greater risks of hospitalization. HIV viral load and antiretroviral therapy status were not associated with hospitalization, although most of the PWH were suppressed (86%). Black PWH were 51% more likely to be hospitalized with COVID-19 compared with other racial/ethnic groups (aRR 1.51; 95% CI: 1.04 to 2.19; P = 0.03). Chronic kidney disease, chronic obstructive pulmonary disease, diabetes, hypertension, obesity, and increased cardiovascular and hepatic fibrosis risk scores were associated with higher hospitalization risk. PWH who were older, not on antiretroviral therapy, and with current CD4 count <350 cells/mm 3 , diabetes, and chronic kidney disease were overrepresented among PWH who required intubation or died. CONCLUSIONS PWH with CD4 count <350 cells/mm 3 , and a history of CD4 count <200 cells/mm 3 , have a clear excess risk of severe COVID-19, accounting for comorbidities associated with severe outcomes. PWH with these risk factors should be prioritized for COVID-19 vaccination and early treatment and monitored closely for worsening illness.
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Affiliation(s)
| | | | | | | | | | - Laura Bamford
- University of California San Diego, San Diego, CA, USA
| | - Darcy Wooten
- University of California San Diego, San Diego, CA, USA
| | | | | | - Sonia Napravnik
- University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | | | | | | | | | | | | | - Maile Karris
- University of California San Diego, San Diego, CA, USA
| | - Davey Smith
- University of California San Diego, San Diego, CA, USA
| | | | - Amanda Willig
- University of Alabama at Birmingham, Birmingham, AL, USA
| | - Joseph J. Eron
- University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Peter Hunt
- University of California, San Francisco, San Francisco, CA, USA
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14
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Nance RM, Delaney JAC, Floyd JS, Saag MS, Moore RD, Keruly JC, Kitahata MM, Whitney BM, Mathews WC, Cachay ER, Burkholder G, Willig AL, Eron JJ, Napravnik S, Crane HM, Heckbert SR. Risk factors for atrial fibrillation in a multicenter United States clinical cohort of people with HIV infection. AIDS 2022; 36:903-905. [PMID: 35220349 PMCID: PMC9081113 DOI: 10.1097/qad.0000000000003180] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
To assess atrial fibrillation risk factors in people with HIV, we identified incident atrial fibrillation in a large clinical cohort of people receiving care. Compared with 970 controls without atrial fibrillation, the 97 with adjudicated incident atrial fibrillation were older, less likely Hispanic, and had more coronary disease, heart failure, and chronic obstructive pulmonary disease. In multivariable analysis, nonuse of antiretroviral therapy and prescription of antiretroviral regimens with multiple core agents were associated with increased atrial fibrillation risk.
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Affiliation(s)
- Robin M Nance
- Departments of Medicine and Epidemiology, University of Washington, Seattle, WA, USA
| | - Joseph A C Delaney
- Departments of Medicine and Epidemiology, University of Washington, Seattle, WA, USA
- Faculty of Pharmacy, University of Manitoba, Winnipeg, MB, Canada
| | - James S Floyd
- Departments of Medicine and Epidemiology, University of Washington, Seattle, WA, USA
| | - Michael S Saag
- Department of Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Richard D Moore
- Department of Medicine, Johns Hopkins University, Baltimore, MD
| | - Jeanne C Keruly
- Department of Medicine, Johns Hopkins University, Baltimore, MD
| | - Mari M Kitahata
- Departments of Medicine and Epidemiology, University of Washington, Seattle, WA, USA
| | - Bridget M Whitney
- Departments of Medicine and Epidemiology, University of Washington, Seattle, WA, USA
| | - W Chris Mathews
- Department of Medicine, University of California, San Diego, CA
| | - Edward R Cachay
- Department of Medicine, University of California, San Diego, CA
| | - Greer Burkholder
- Department of Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Amanda L Willig
- Department of Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Joseph J Eron
- Department of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Sonia Napravnik
- Department of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Heidi M Crane
- Departments of Medicine and Epidemiology, University of Washington, Seattle, WA, USA
| | - Susan R Heckbert
- Departments of Medicine and Epidemiology, University of Washington, Seattle, WA, USA
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15
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Lesko CR, Hutton HE, Edwards JK, McCaul ME, Fojo AT, Keruly JC, Moore RD, Chander G. Alcohol Use Disorder and Recent Alcohol Use and HIV Viral Non-Suppression Among People Engaged in HIV Care in an Urban Clinic, 2014-2018. AIDS Behav 2022; 26:1299-1307. [PMID: 34626264 PMCID: PMC8940688 DOI: 10.1007/s10461-021-03487-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/03/2021] [Indexed: 01/28/2023]
Abstract
We estimated joint associations between having history of alcohol use disorder (AUD) (based on prior ICD-9/ICD-10 codes) and recent self-reported alcohol use and viral non-suppression (≥ 1 viral load measurement > 20 copies/mL in the same calendar year as alcohol consumption was reported) among patients on ART enrolled in routine care, 2014-2018, in an urban specialty clinic. Among 1690 patients, 26% had an AUD, 21% reported high-risk alcohol use, and 39% had viral non-suppression. Relative to person-years in which people without AUD reported not drinking, prevalence of viral non-suppression was higher in person-years when people with AUD reported drinking at any level; prevalence of viral non-suppression was not significantly higher in person-years when people with AUD reported not drinking or person-years when people without AUD reported drinking at any level. No level of alcohol use may be "safe" for people with a prior AUD with regard to maintaining viral suppression.
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Affiliation(s)
- Catherine R Lesko
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe St, Baltimore, MD, 21205, USA.
| | - Heidi E Hutton
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Jessie K Edwards
- Department of Epidemiology, University of North Carolina, Chapel Hill, NC, USA
| | - Mary E McCaul
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Anthony T Fojo
- Division of General Internal Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Jeanne C Keruly
- Division of General Internal Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Richard D Moore
- Division of General Internal Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Geetanjali Chander
- Division of General Internal Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
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16
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El-Nahal WG, Shen NM, Keruly JC, Jones JL, Fojo AT, Lau B, Manabe YC, Moore RD, Gebo KA, Lesko CR, Chander G. Telemedicine and visit completion among people with HIV during the coronavirus disease 2019 pandemic compared with prepandemic. AIDS 2022; 36:355-362. [PMID: 34711737 PMCID: PMC8795480 DOI: 10.1097/qad.0000000000003119] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Telemedicine became the primary mode of delivering care during the COVID-19 pandemic. We describe the impact of telemedicine on access to care for people with HIV (PWH) by comparing the proportion of PWH engaged in care prior to and during the COVID-19 pandemic. DESIGN AND METHODS We conducted an observational analysis of patients enrolled in the Johns Hopkins HIV Clinical Cohort, a single-center cohort of patients at an urban HIV subspecialty clinic affiliated with an academic center. Due to the COVID-19 pandemic, the clinic transitioned from in-person to mostly telemedicine visits. We compared patients receiving care in two time periods. The prepandemic period included 2010 people with at least one visit scheduled between 1 September 2019 and 15 March 2020. The pandemic period included 1929 people with at least one visit scheduled between 16 March 2020 and 30 September 2020. We determined the proportion of patients completing at least one of their scheduled visits during each period. RESULTS Visit completion increased significantly from 88% prepandemic to 91% during the pandemic (P = 0.008). Visit completion improved significantly for patients age 20-39 (82 to 92%, P < 0.001), women (86 to 93%, P < 0.001), Black patients (88 to 91%, P = 0.002) and patients with detectable viremia (77 to 85%, P = 0.06) during the pandemic. Only 29% of people who completed at least one telemedicine visit during the pandemic did so as a video (versus telephone) visit. CONCLUSION During the pandemic when care was widely delivered via telemedicine, visit completion improved among groups with lower prepandemic engagement but most were limited to telephone visits.
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Affiliation(s)
- Walid G El-Nahal
- Department of Medicine, Johns Hopkins University School of Medicine
| | - Nicola M Shen
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Jeanne C Keruly
- Department of Medicine, Johns Hopkins University School of Medicine
| | - Joyce L Jones
- Department of Medicine, Johns Hopkins University School of Medicine
| | - Anthony T Fojo
- Department of Medicine, Johns Hopkins University School of Medicine
| | - Bryan Lau
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Yukari C Manabe
- Department of Medicine, Johns Hopkins University School of Medicine
| | - Richard D Moore
- Department of Medicine, Johns Hopkins University School of Medicine
| | - Kelly A Gebo
- Department of Medicine, Johns Hopkins University School of Medicine
| | - Catherine R Lesko
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
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17
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Duggal P, Penson T, Manley HN, Vergara C, Munday RM, Duchen D, Linton EA, Zurn A, Keruly JC, Mehta SH, Thomas DL. Post-sequelae symptoms and comorbidities after COVID-19. J Med Virol 2022; 94:2060-2066. [PMID: 35032030 PMCID: PMC8958980 DOI: 10.1002/jmv.27586] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2021] [Revised: 01/06/2022] [Accepted: 01/07/2022] [Indexed: 11/23/2022]
Abstract
The frequency, severity, and forms of symptoms months after coronavirus 2019 (COVID‐19) are poorly understood, especially in community settings. To better understand and characterize symptoms months after community‐based COVID‐19, a retrospective cohort analysis was conducted. Three hundred and twenty‐eight consecutive persons with a positive test for SARS‐CoV‐2 in the Johns Hopkins Health System, Maryland, March−May 2020, were selected for the study. Symptom occurrence and severity were measured through questionnaires. Of 328 persons evaluated, a median of 242 days (109−478 days) from the initial positive SARS‐CoV‐2 test, 33.2% reported not being fully recovered and 4.9% reported symptoms that constrained daily activities. Compared to those who reported being fully recovered, those with post‐acute sequelae were more likely to report a prior history of heart attack (p < 0.01). Among those reporting long‐term symptoms, men and women were equally represented (men = 34.8%, women = 34.6%), but only women reported symptoms that constrained daily activities, and 56% of them were caregivers. The types of new or persistent symptoms varied, and for many, included a deviation from prior COVID‐19 health, such as being less able to exercise, walk, concentrate, or breathe. A limitation is that self‐report of symptoms might be biased and/or caused by factors other than COVID‐19. Overall, even in a community setting, symptoms may persist months after COVID‐19 reducing daily activities including caring for dependents. Even months after coronavirus 2019 a substantial proportion of persons continue to have symptoms that might restrict their daily activities. Further research is needed to prevent this complication especially as the pandemic spreads over the world.
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Affiliation(s)
- Priya Duggal
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland.,Department of Medicine, Division of Infectious Disease, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Tristan Penson
- Department of Medicine, Division of Infectious Disease, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Hannah N Manley
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Candelaria Vergara
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Rebecca M Munday
- Department of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Dylan Duchen
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Elizabeth A Linton
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Amber Zurn
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Jeanne C Keruly
- Department of Medicine, Division of Infectious Disease, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Shruti H Mehta
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland.,Department of Medicine, Division of Infectious Disease, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - David L Thomas
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland.,Department of Medicine, Division of Infectious Disease, Johns Hopkins University School of Medicine, Baltimore, Maryland
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18
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Bender Ignacio RA, Shapiro AE, Nance RM, Whitney BM, Delaney J, Bamford L, Wooten D, Karris M, Mathews WC, Kim HN, Van Rompaey SE, Keruly JC, Burkholder G, Napravnik S, Mayer KH, Jacobson J, Saag MS, Moore RD, Eron JJ, Willig AL, Christopoulos KA, Martin J, Hunt PW, Crane HM, Kitahata MM, Cachay E. Racial and ethnic disparities in COVID-19 disease incidence independent of comorbidities, among people with HIV in the US. medRxiv 2021:2021.12.07.21267296. [PMID: 34909782 PMCID: PMC8669849 DOI: 10.1101/2021.12.07.21267296] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES To define the incidence of clinically-detected COVID-19 in people with HIV (PWH) in the US and evaluate how racial and ethnic disparities, comorbidities, and HIV-related factors contribute to risk of COVID-19. DESIGN Observational study within the CFAR Network of Integrated Clinical Systems cohort in 7 cities during 2020. METHODS We calculated cumulative incidence rates of COVID-19 diagnosis among PWH in routine care by key characteristics including race/ethnicity, current and lowest CD4 count, and geographic area. We evaluated risk factors for COVID-19 among PWH using relative risk regression models adjusted with disease risk scores. RESULTS Among 16,056 PWH in care, of whom 44.5% were Black, 12.5% were Hispanic, with a median age of 52 years (IQR 40-59), 18% had a current CD4 count < 350, including 7% < 200; 95.5% were on antiretroviral therapy, and 85.6% were virologically suppressed. Overall in 2020, 649 PWH were diagnosed with COVID-19 for a rate of 4.94 cases per 100 person-years. The cumulative incidence of COVID-19 was 2.4-fold and 1.7-fold higher in Hispanic and Black PWH respectively, than non-Hispanic White PWH. In adjusted analyses, factors associated with COVID-19 included female sex, Hispanic or Black identity, lowest historical CD4 count <350 (proxy for CD4 nadir), current low CD4/CD8 ratio, diabetes, and obesity. CONCLUSIONS Our results suggest that the presence of structural racial inequities above and beyond medical comorbidities increased the risk of COVID-19 among PWHPWH with immune exhaustion as evidenced by lowest historical CD4 or current low CD4:CD8 ratio had greater risk of COVID-19.
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Affiliation(s)
- R A Bender Ignacio
- University of Washington, Seattle, WA, USA
- Fred Hutchinson Cancer Research Center
| | - A E Shapiro
- University of Washington, Seattle, WA, USA
- Fred Hutchinson Cancer Research Center
| | - R M Nance
- University of Washington, Seattle, WA, USA
| | | | | | - L Bamford
- University of California San Diego, San Diego, CA, USA
| | - D Wooten
- University of California San Diego, San Diego, CA, USA
| | - M Karris
- University of California San Diego, San Diego, CA, USA
| | - W C Mathews
- University of California San Diego, San Diego, CA, USA
| | - H N Kim
- University of Washington, Seattle, WA, USA
| | | | - J C Keruly
- Johns Hopkins School of Medicine, Baltimore, MD
| | - G Burkholder
- University of Alabama at Birmingham, Birmingham, AL, USA
| | - S Napravnik
- University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - K H Mayer
- Fenway Health and Harvard Medical School, Boston, MA, USA
| | - J Jacobson
- Case Western Reserve University, Cleveland, OH, USA
| | - M S Saag
- University of Alabama at Birmingham, Birmingham, AL, USA
| | - R D Moore
- Johns Hopkins School of Medicine, Baltimore, MD
| | - J J Eron
- University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - A L Willig
- University of Alabama at Birmingham, Birmingham, AL, USA
| | | | - J Martin
- University of California, San Francisco, San Francisco, CA, USA
| | - P W Hunt
- University of California, San Francisco, San Francisco, CA, USA
| | - H M Crane
- University of Washington, Seattle, WA, USA
| | | | - E Cachay
- University of California San Diego, San Diego, CA, USA
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Kim J, Lesko CR, Fojo AT, Keruly JC, Moore RD, Chander G, Lau B. The Effect of Buprenorphine on Human Immunodeficiency Virus Viral Suppression. Clin Infect Dis 2021; 73:1951-1956. [PMID: 34171087 PMCID: PMC8664419 DOI: 10.1093/cid/ciab578] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND Opioid use is prevalent among people living with human immunodeficiency virus (HIV; PLWH) and adversely affects HIV outcomes. We assessed the effect of buprenorphine (BUP) initiation on subsequent HIV viral loads. METHODS We identified PLWH from the Johns Hopkins HIV Clinical Cohort who initiated BUP between 2002 and 2017. Poisson regression with robust variance was used to estimate the prevalence of viral suppression (<200 copies/mL) before and after BUP initiation. We matched individuals who initiated BUP with controls based on viral load measurement dates and used prior event rate ratio (PERR) methods to estimate the effect of BUP initiation on viral suppression. PERR methods account for unmeasured confounders. RESULTS We identified 279 PLWH who initiated BUP. After BUP initiation, PLWH were more likely to be virally suppressed (prevalence ratio [PR], 1.19; 95% confidence interval [CI], 1.03-1.37). After matching PLWH who initiated BUP to controls and accounting for measured and unmeasured confounders, BUP initiation increased viral suppression for both those on antiretroviral therapy (ART) at baseline (PERR PR, 1.08; 95% CI, 1.00-1.18) and those not on ART at baseline (PR, 1.31; 95% CI, 1.10-1.61). CONCLUSIONS Our results indicate that the initiation of BUP results in an increase in the probability of being virally suppressed after accounting for both measured and unmeasured confounders. Persons with opioid use disorder should initiate BUP to not only treat substance use but also to increase viral suppression allowing for treatment as prevention.
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Affiliation(s)
- Jongyeon Kim
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Catherine R Lesko
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Anthony T Fojo
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jeanne C Keruly
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Richard D Moore
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Geetanjali Chander
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Bryan Lau
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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20
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Demko ZO, Antar AAR, Blair PW, Lambrou AS, Yu T, Brown D, Walch SN, Armstrong DT, Mostafa HH, Keruly JC, Thomas DL, Manabe YC, Mehta SH. Clustering of SARS-CoV-2 Infections in Households of Patients Diagnosed in the Outpatient Setting in Baltimore, Maryland. Open Forum Infect Dis 2021; 8:ofab121. [PMID: 34796248 PMCID: PMC7989179 DOI: 10.1093/ofid/ofab121] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Accepted: 03/09/2021] [Indexed: 11/16/2022] Open
Abstract
In an outpatient cohort in Maryland, clustering of severe acute respiratory
syndrome coronavirus 2 (SARS-CoV-2) positivity within households was high, with
76% of 74 households reporting at least 1 other symptomatic person and 66%
reporting another person who tested SARS-CoV-2 positive. SARS-CoV-2 positivity
among household members was associated with larger household size and bedroom
sharing.
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Affiliation(s)
- Zoe O Demko
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Annukka A R Antar
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Paul W Blair
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,Henry M. Jackson Foundation, Bethesda, Maryland, USA
| | - Anastasia S Lambrou
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Tong Yu
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Diane Brown
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Samantha N Walch
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Derek T Armstrong
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Heba H Mostafa
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jeanne C Keruly
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - David L Thomas
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Yukari C Manabe
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Shruti H Mehta
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
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21
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Shapiro AE, Bender Ignacio RA, Whitney BM, Delaney JA, Nance RM, Bamford L, Wooten D, Keruly JC, Burkholder G, Napravnik S, Mayer KH, Webel AR, Kim HN, Van Rompaey SE, Christopoulos K, Jacobson J, Karris M, Smith D, Johnson MO, Willig A, Eron JJ, Hunt P, Moore RD, Saag MS, Mathews WC, Crane HM, Cachay ER, Kitahata MM. Factors associated with severity of COVID-19 disease in a multicenter cohort of people with HIV in the United States, March-December 2020. medRxiv 2021:2021.10.15.21265063. [PMID: 34704092 PMCID: PMC8547524 DOI: 10.1101/2021.10.15.21265063] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
BACKGROUND Understanding the spectrum of SARS-CoV-2 infection and COVID-19 disease in people with HIV (PWH) is critical to provide clinical guidance and implement risk-reduction strategies. OBJECTIVE To characterize COVID-19 in PWH in the United States and identify predictors of disease severity. DESIGN Observational cohort study. SETTING Geographically diverse clinical sites in the CFAR Network of Integrated Clinical Systems (CNICS). PARTICIPANTS Adults receiving HIV care through December 31, 2020. MEASUREMENTS COVID-19 cases and severity (hospitalization, intensive care, death). RESULTS Of 16,056 PWH in care, 649 were diagnosed with COVID-19 between March-December 2020. Case fatality was 2%; 106 (16.3%) were hospitalized and 12 died. PWH with current CD4 count <350 cells/mm 3 (aRR 2.68; 95%CI 1.93-3.71; P<.001) or lowest recorded CD4 count <200 (aRR 1.67; 95%CI 1.18-2.36; P<.005) had greater risk of hospitalization. HIV viral load suppression and antiretroviral therapy (ART) status were not associated with hospitalization, although the majority of PWH were suppressed (86%). Black PWH were 51% more likely to be hospitalized with COVID-19 compared to other racial/ethnic groups (aRR 1.51; 95%CI 1.04-2.19, P=.03). Chronic kidney disease (CKD), chronic obstructive pulmonary disease, diabetes, hypertension, obesity, and increased cardiovascular and hepatic fibrosis risk scores were associated with higher risk of hospitalization. PWH who were older, not on ART, with current CD4 <350, diabetes, and CKD were overrepresented amongst PWH who required intubation or died. LIMITATIONS Unable to compare directly to persons without HIV; underestimate of total COVID-19 cases. CONCLUSIONS PWH with CD4 <350 cells/mm 3 , low CD4/CD8 ratio, and history of CD4 <200, have a clear excess risk of severe COVID-19, after accounting for comorbidities also associated with severe outcomes. PWH with these risk factors should be prioritized for COVID-19 vaccination, early treatment, and monitored closely for worsening illness.
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22
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Monroe AK, Levy ME, Greenberg AE, Keruly JC, Moore RD, Horberg MA, Kulie P, Mohanraj BS, Kumar PN, Castel AD. Integrase Inhibitor Prescribing Disparities in the DC and Johns Hopkins HIV Cohorts. Open Forum Infect Dis 2021; 8:ofab338. [PMID: 34631925 PMCID: PMC8496514 DOI: 10.1093/ofid/ofab338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 06/29/2021] [Indexed: 11/20/2022] Open
Abstract
Integrase inhibitors (INSTIs) are recommended by expert panels as initial therapy
for people with HIV. Because there can be disparities in prescribing and uptake
of novel and/or recommended therapies, this analysis assessed potential INSTI
prescribing disparities using a combined data set from the Johns Hopkins HIV
Clinical Cohort and the DC Cohort. We performed multivariable logistic
regression to identify factors associated with ever being prescribed an INSTI.
Disparities were noted, including clinic location, age, and being transgender.
Identifying disparities may allow clinicians to focus their attention on these
individuals and ensure that therapy decisions are grounded in valid clinical
reasons.
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Affiliation(s)
- Anne K Monroe
- The George Washington University, Washington, DC, USA
| | | | | | - Jeanne C Keruly
- The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Richard D Moore
- The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | | | - Paige Kulie
- The George Washington University, Washington, DC, USA
| | | | - Princy N Kumar
- Georgetown University School of Medicine, Washington, DC, USA
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23
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Jabour SM, Chander G, Riekert KA, Keruly JC, Herne K, Hutton H, Beach MC, Lau B, Moore RD, Monroe AK. The Patient Reported Outcomes as a Clinical Tool (PROACT) Pilot Study: What Can be Gained by Sharing Computerized Patient-Reported Mental Health and Substance Use Symptoms with Providers in HIV Care? AIDS Behav 2021; 25:2963-2972. [PMID: 33559775 DOI: 10.1007/s10461-021-03175-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/18/2021] [Indexed: 10/22/2022]
Abstract
Substance use and mental health (SU/MH) disorders are insufficiently recognized in HIV care. We examined whether conveying SU/MH screening results to patients and providers increased SU/MH discussions and action plans. Intervention participants completed a computerized patient-reported questionnaire before their HIV visit; screened positive on ≥ 1 measure: depression, anxiety, PTSD symptoms, at-risk alcohol use, or drug use; and reviewed screening results to decide which to prioritize with their provider. Screening results and clinical recommendations were conveyed to providers via medical record. A historic control included patients with positive screens but no conveyance to patient or provider. The patient-provider encounter was audio-recorded, transcribed, and coded. For the overall sample (n = 70; 38 control, 32 intervention), mean age (SD) was 51.8 (10.3), 61.4% were male, and 82.9% were Black. Overall, 93.8% raised SU/MH in the intervention compared to 50.0% in the control (p < 0.001). Action plans were made for 40.0% of intervention and 10.5% of control encounters (p = 0.049). Conveying screening results with clinical recommendations increased SU/MH action plans, warranting further research on this intervention to address SU/MH needs.
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24
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Antar AAR, Yu T, Pisanic N, Azamfirei R, Tornheim JA, Brown DM, Kruczynski K, Hardick JP, Sewell T, Jang M, Church T, Walch SN, Reuland C, Bachu VS, Littlefield K, Park HS, Ursin RL, Ganesan A, Kusemiju O, Barnaba B, Charles C, Prizzi M, Johnstone JR, Payton C, Dai W, Fuchs J, Massaccesi G, Armstrong DT, Townsend JL, Keller SC, Demko ZO, Hu C, Wang MC, Sauer LM, Mostafa HH, Keruly JC, Mehta SH, Klein SL, Cox AL, Pekosz A, Heaney CD, Thomas DL, Blair PW, Manabe YC. Delayed Rise of Oral Fluid Antibodies, Elevated BMI, and Absence of Early Fever Correlate With Longer Time to SARS-CoV-2 RNA Clearance in a Longitudinally Sampled Cohort of COVID-19 Outpatients. Open Forum Infect Dis 2021; 8:ofab195. [PMID: 34095338 PMCID: PMC8083254 DOI: 10.1093/ofid/ofab195] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 04/13/2021] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Sustained molecular detection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) RNA in the upper respiratory tract (URT) in mild to moderate coronavirus disease 2019 (COVID-19) is common. We sought to identify host and immune determinants of prolonged SARS-CoV-2 RNA detection. METHODS Ninety-five symptomatic outpatients self-collected midturbinate nasal, oropharyngeal (OP), and gingival crevicular fluid (oral fluid) samples at home and in a research clinic a median of 6 times over 1-3 months. Samples were tested for viral RNA, virus culture, and SARS-CoV-2 and other human coronavirus antibodies, and associations were estimated using Cox proportional hazards models. RESULTS Viral RNA clearance, as measured by SARS-CoV-2 reverse transcription polymerase chain reaction (RT-PCR), in 507 URT samples occurred a median (interquartile range) 33.5 (17-63.5) days post-symptom onset. Sixteen nasal-OP samples collected 2-11 days post-symptom onset were virus culture positive out of 183 RT-PCR-positive samples tested. All participants but 1 with positive virus culture were negative for concomitant oral fluid anti-SARS-CoV-2 antibodies. The mean time to first antibody detection in oral fluid was 8-13 days post-symptom onset. A longer time to first detection of oral fluid anti-SARS-CoV-2 S antibodies (adjusted hazard ratio [aHR], 0.96; 95% CI, 0.92-0.99; P = .020) and body mass index (BMI) ≥25 kg/m2 (aHR, 0.37; 95% CI, 0.18-0.78; P = .009) were independently associated with a longer time to SARS-CoV-2 viral RNA clearance. Fever as 1 of first 3 COVID-19 symptoms correlated with shorter time to viral RNA clearance (aHR, 2.06; 95% CI, 1.02-4.18; P = .044). CONCLUSIONS We demonstrate that delayed rise of oral fluid SARS-CoV-2-specific antibodies, elevated BMI, and absence of early fever are independently associated with delayed URT viral RNA clearance.
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Affiliation(s)
- Annukka A R Antar
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Tong Yu
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Nora Pisanic
- Department of Environmental Health and Engineering, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Razvan Azamfirei
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jeffrey A Tornheim
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Diane M Brown
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Kate Kruczynski
- Department of Environmental Health and Engineering, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Justin P Hardick
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Thelio Sewell
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Minyoung Jang
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Taylor Church
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Samantha N Walch
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Carolyn Reuland
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Vismaya S Bachu
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Kirsten Littlefield
- W. Harry Feinstone Department of Molecular Microbiology and Immunology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Han-Sol Park
- W. Harry Feinstone Department of Molecular Microbiology and Immunology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Rebecca L Ursin
- Department of Biochemistry and Molecular Biology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Abhinaya Ganesan
- W. Harry Feinstone Department of Molecular Microbiology and Immunology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Oyinkansola Kusemiju
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Brittany Barnaba
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Curtisha Charles
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Michelle Prizzi
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jaylynn R Johnstone
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Christine Payton
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Weiwei Dai
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Joelle Fuchs
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Guido Massaccesi
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Derek T Armstrong
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jennifer L Townsend
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Sara C Keller
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Zoe O Demko
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Chen Hu
- Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Mei-Cheng Wang
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Lauren M Sauer
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Heba H Mostafa
- Department of Biochemistry and Molecular Biology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Jeanne C Keruly
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Shruti H Mehta
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Sabra L Klein
- W. Harry Feinstone Department of Molecular Microbiology and Immunology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Department of Biochemistry and Molecular Biology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Andrea L Cox
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- W. Harry Feinstone Department of Molecular Microbiology and Immunology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Andrew Pekosz
- W. Harry Feinstone Department of Molecular Microbiology and Immunology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Christopher D Heaney
- Department of Environmental Health and Engineering, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - David L Thomas
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Paul W Blair
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Yukari C Manabe
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- W. Harry Feinstone Department of Molecular Microbiology and Immunology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
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25
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Pettit AC, Bian A, Schember CO, Rebeiro PF, Keruly JC, Mayer KH, Mathews WC, Moore RD, Crane HM, Geng E, Napravnik S, Shepherd BE, Mugavero MJ. Development and Validation of a Multivariable Prediction Model for Missed HIV Health Care Provider Visits in a Large US Clinical Cohort. Open Forum Infect Dis 2021; 8:ofab130. [PMID: 34327249 PMCID: PMC8314944 DOI: 10.1093/ofid/ofab130] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Accepted: 03/12/2021] [Indexed: 11/12/2022] Open
Abstract
Background Identifying individuals at high risk of missing HIV care provider visits could support proactive intervention. Previous prediction models for missed visits have not incorporated data beyond the individual level. Methods We developed prediction models for missed visits among people with HIV (PWH) with ≥1 follow-up visit in the Center for AIDS Research Network of Integrated Clinical Systems from 2010 to 2016. Individual-level (medical record data and patient-reported outcomes), community-level (American Community Survey), HIV care site–level (standardized clinic leadership survey), and structural-level (HIV criminalization laws, Medicaid expansion, and state AIDS Drug Assistance Program budget) predictors were included. Models were developed using random forests with 10-fold cross-validation; candidate models with the highest area under the curve (AUC) were identified. Results Data from 382 432 visits among 20 807 PWH followed for a median of 3.8 years were included; the median age was 44 years, 81% were male, 37% were Black, 15% reported injection drug use, and 57% reported male-to-male sexual contact. The highest AUC was 0.76, and the strongest predictors were at the individual level (prior visit adherence, age, CD4+ count) and community level (proportion living in poverty, unemployed, and of Black race). A simplified model, including readily accessible variables available in a web-based calculator, had a slightly lower AUC of .700. Conclusions Prediction models validated using multilevel data had a similar AUC to previous models developed using only individual-level data. The strongest predictors were individual-level variables, particularly prior visit adherence, though community-level variables were also predictive. Absent additional data, PWH with previous missed visits should be prioritized by interventions to improve visit adherence.
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Affiliation(s)
- April C Pettit
- Division of Infectious Diseases, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Division of Epidemiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Aihua Bian
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Cassandra O Schember
- Division of Epidemiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Peter F Rebeiro
- Division of Infectious Diseases, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Division of Epidemiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Jeanne C Keruly
- Division of Infectious Diseases, Johns Hopkins University, Baltimore, Maryland, USA
| | - Kenneth H Mayer
- Fenway Health and Harvard Medical School, Boston, Massachusetts, USA
| | - W Christopher Mathews
- Department of Medicine, University of California San Diego, San Diego, California, USA
| | - Richard D Moore
- Division of Infectious Diseases, Johns Hopkins University, Baltimore, Maryland, USA
| | - Heidi M Crane
- Division of Infectious Diseases, University of Washington School of Medicine, Seattle, Washington, USA
| | - Elvin Geng
- Division of Infectious Diseases, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Sonia Napravnik
- Division of Infectious Diseases, University of North Carolina Chapel Hill School of Medicine, Chapel Hill, North Carolina, USA
| | - Bryan E Shepherd
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Michael J Mugavero
- Division of Infectious Diseases, University of Alabama at Birmingham School of Medicine, Birmingham, Alabama, USA
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Antar AAR, Yu T, Pisanic N, Azamfirei R, Tornheim JA, Brown DM, Kruczynski K, Hardick JP, Sewell T, Jang M, Church T, Walch SN, Reuland C, Bachu VS, Littlefield K, Park HS, Ursin RL, Ganesan A, Kusemiju O, Barnaba B, Charles C, Prizzi M, Johnstone JR, Payton C, Dai W, Fuchs J, Massaccesi G, Armstrong DT, Townsend JL, Keller SC, Demko ZO, Hu C, Wang MC, Sauer LM, Mostafa HH, Keruly JC, Mehta SH, Klein SL, Cox AL, Pekosz A, Heaney CD, Thomas DL, Blair PW, Manabe YC. Delayed rise of oral fluid antibodies, elevated BMI, and absence of early fever correlate with longer time to SARS-CoV-2 RNA clearance in an longitudinally sampled cohort of COVID-19 outpatients. medRxiv 2021. [PMID: 33688688 DOI: 10.1101/2021.03.02.21252420] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Background Sustained molecular detection of SARS-CoV-2 RNA in the upper respiratory tract (URT) in mild to moderate COVID-19 is common. We sought to identify host and immune determinants of prolonged SARS-CoV-2 RNA detection. Methods Ninety-five outpatients self-collected mid-turbinate nasal, oropharyngeal (OP), and gingival crevicular fluid (oral fluid) samples at home and in a research clinic a median of 6 times over 1-3 months. Samples were tested for viral RNA, virus culture, and SARS-CoV-2 and other human coronavirus antibodies, and associations were estimated using Cox proportional hazards models. Results Viral RNA clearance, as measured by SARS-CoV-2 RT-PCR, in 507 URT samples occurred a median (IQR) 33.5 (17-63.5) days post-symptom onset. Sixteen nasal-OP samples collected 2-11 days post-symptom onset were virus culture positive out of 183 RT-PCR positive samples tested. All participants but one with positive virus culture were negative for concomitant oral fluid anti-SARS-CoV-2 antibodies. The mean time to first antibody detection in oral fluid was 8-13 days post-symptom onset. A longer time to first detection of oral fluid anti-SARS-CoV-2 S antibodies (aHR 0.96, 95% CI 0.92-0.99, p=0.020) and BMI ≥ 25kg/m 2 (aHR 0.37, 95% CI 0.18-0.78, p=0.009) were independently associated with a longer time to SARS-CoV-2 viral RNA clearance. Fever as one of first three COVID-19 symptoms correlated with shorter time to viral RNA clearance (aHR 2.06, 95% CI 1.02-4.18, p=0.044). Conclusions We demonstrate that delayed rise of oral fluid SARS-CoV-2-specific antibodies, elevated BMI, and absence of early fever are independently associated with delayed URT viral RNA clearance.
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Blair PW, Brown DM, Jang M, Antar AAR, Keruly JC, Bachu VS, Townsend JL, Tornheim JA, Keller SC, Sauer L, Thomas DL, Manabe YC. The Clinical Course of COVID-19 in the Outpatient Setting: A Prospective Cohort Study. Open Forum Infect Dis 2021; 8:ofab007. [PMID: 33614816 PMCID: PMC7881750 DOI: 10.1093/ofid/ofab007] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Accepted: 01/04/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Outpatient coronavirus disease 2019 (COVID-19) has been insufficiently characterized. To determine the progression of disease and determinants of hospitalization, we conducted a prospective cohort study. METHODS Outpatient adults with positive reverse transcription polymerase chain reaction results for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) were recruited by phone between April 21 and July 23, 2020, after receiving outpatient or emergency department testing within a large health network in Maryland, United States. Symptoms were collected by participants on days 0, 3, 7, 14, 21, and 28, and portable pulse oximeter oxygen saturation (SaO2), heart rate, and temperature were collected for 15 consecutive days. Baseline demographics, comorbid conditions, and vital signs were evaluated for risk of subsequent hospitalization using negative binomial and logistic regression. RESULTS Among 118 SARS-CoV-2-infected outpatients, the median age (interquartile range [IQR]) was 56.0 (50.0-63.0) years, and 50 (42.4%) were male. Among individuals in the first week of illness (n = 61), the most common symptoms included weakness/fatigue (65.7%), cough (58.8%), headache (45.6%), chills (38.2%), and anosmia (27.9%). Participants returned to their usual health a median (IQR) of 20 (13-38) days from symptom onset, and 66.0% of respondents were at their usual health during the fourth week of illness. Over 28 days, 10.9% presented to the emergency department and 7.6% required hospitalization. The area under the receiver operating characteristics curve for the initial home SaO2 for predicting subsequent hospitalization was 0.86 (95% CI, 0.73-0.99). CONCLUSIONS Symptoms often persisted but uncommonly progressed to hospitalization among outpatients with COVID-19. Home SaO2 may be a helpful tool to stratify risk of hospitalization.
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Affiliation(s)
- Paul W Blair
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Austere Environments Consortium for Enhanced Sepsis Outcomes, Henry M. Jackson Foundation, Bethesda, Maryland, USA
| | - Diane M Brown
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Minyoung Jang
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Annukka A R Antar
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jeanne C Keruly
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Vismaya S Bachu
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jennifer L Townsend
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jeffrey A Tornheim
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Sara C Keller
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Lauren Sauer
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - David L Thomas
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Yukari C Manabe
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Antar AA, Jenike KM, Jang S, Rigau DN, Reeves DB, Hoh R, Krone MR, Keruly JC, Moore RD, Schiffer JT, Nonyane BA, Hecht FM, Deeks SG, Siliciano JD, Ho YC, Siliciano RF. Longitudinal study reveals HIV-1-infected CD4+ T cell dynamics during long-term antiretroviral therapy. J Clin Invest 2020; 130:3543-3559. [PMID: 32191639 PMCID: PMC7324206 DOI: 10.1172/jci135953] [Citation(s) in RCA: 61] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Accepted: 03/17/2020] [Indexed: 12/11/2022] Open
Abstract
Proliferation of CD4+ T cells harboring HIV-1 proviruses is a major contributor to viral persistence in people on antiretroviral therapy (ART). To determine whether differential rates of clonal proliferation or HIV-1-specific cytotoxic T lymphocyte (CTL) pressure shape the provirus landscape, we performed an intact proviral DNA assay (IPDA) and obtained 661 near-full-length provirus sequences from 8 individuals with suppressed viral loads on ART at time points 7 years apart. We observed slow decay of intact proviruses but no changes in the proportions of various types of defective proviruses. The proportion of intact proviruses in expanded clones was similar to that of defective proviruses in clones. Intact proviruses observed in clones did not have more escaped CTL epitopes than intact proviruses observed as singlets. Concordantly, total proviruses at later time points or observed in clones were not enriched in escaped or unrecognized epitopes. Three individuals with natural control of HIV-1 infection (controllers) on ART, included because controllers have strong HIV-1-specific CTL responses, had a smaller proportion of intact proviruses but a distribution of defective provirus types and escaped or unrecognized epitopes similar to that of the other individuals. This work suggests that CTL selection does not significantly check clonal proliferation of infected cells or greatly alter the provirus landscape in people on ART.
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Affiliation(s)
- Annukka A.R. Antar
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Katharine M. Jenike
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Sunyoung Jang
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Danielle N. Rigau
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Daniel B. Reeves
- Vaccine and Infectious Diseases Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | | | - Melissa R. Krone
- Department of Epidemiology and Biostatistics, UCSF, San Francisco, California, USA
| | - Jeanne C. Keruly
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Richard D. Moore
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Joshua T. Schiffer
- Vaccine and Infectious Diseases Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
- Department of Medicine, University of Washington, Seattle, Washington, USA
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Bareng A.S. Nonyane
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | | | | | - Janet D. Siliciano
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Ya-Chi Ho
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Robert F. Siliciano
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Howard Hughes Medical Institute, Baltimore, Maryland, USA
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Modi RA, McGwin GL, Willig JH, Westfall AO, Griffin RL, Amico R, Martin KD, Raper JL, Keruly JC, Golin CE, Zinski A, Napravnik S, Crane HM, Mugavero MJ. Factors Associated with HIV Disclosure Status Among iENGAGE Cohort of New to HIV Care Patients. AIDS Patient Care STDS 2020; 34:213-227. [PMID: 32396474 DOI: 10.1089/apc.2019.0271] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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: 11/13/2022] Open
Abstract
HIV disclosure is an important behavior with implications for HIV treatment and prevention but understudied among new to HIV care patients who face unique challenges adjusting to a new diagnosis. This study evaluated the factors associated with HIV disclosure status and patterns of HIV disclosure among new to HIV care patients. A cross-sectional study was conducted evaluating the iENGAGE (integrating ENGagement and Adherence Goals upon Entry) cohort. Participants were enrolled in this randomized behavioral trial between December 2013 and June 2016. The primary and secondary outcomes included HIV disclosure status (Yes/No) and patterns of disclosure (Broad, Selective and Nondisclosure), respectively. Logistic and Multinomial Logistic Regression were used to evaluate the association of participant factors with HIV disclosure and patterns of HIV disclosure, respectively. Of 371 participants, the average age was 37 ± 12 years, 79.3% were males, and 62.3% were African Americans. A majority of participants (78.4%) disclosed their HIV status at baseline, 63.1% were broad disclosers and 15.2% were selective disclosers. In multivariable regression, black race, emotional support, and unmet needs predicted any HIV and broad disclosure, whereas males, emotional support, active coping, and acceptance were associated with selective disclosure. Interventions to promote early disclosure should focus on coping strategies and unmet needs, particularly among black and male people living with HIV initiating care.
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Affiliation(s)
- Riddhi A. Modi
- Department of Pathology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Gerald L. McGwin
- Department of Epidemiology, and University of Alabama at Birmingham, Birmingham, Alabama
| | - James H. Willig
- Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Andrew O. Westfall
- Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Russell L. Griffin
- Department of Epidemiology, and University of Alabama at Birmingham, Birmingham, Alabama
| | - Rivet Amico
- Department of Health Behavior and Education, University of Connecticut, Storrs, Connecticut
| | - Kimberly D. Martin
- Department of Epidemiology, and University of Alabama at Birmingham, Birmingham, Alabama
| | - James L. Raper
- Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Jeanne C. Keruly
- Department of Medicine, Johns Hopkins Hospital, Baltimore, Maryland
| | - Carol E. Golin
- Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Anne Zinski
- Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Sonia Napravnik
- Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Heidi M. Crane
- Department of Medicine, University of Washington, Seattle, Washington
| | - Michael J. Mugavero
- Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
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Gardner LI, Marks G, Patel U, Cachay E, Wilson TE, Stirratt M, Rodriguez A, Sullivan M, Keruly JC, Giordano TP. Gaps Up To 9 Months Between HIV Primary Care Visits Do Not Worsen Viral Load. AIDS Patient Care STDS 2018; 32:157-164. [PMID: 29630849 PMCID: PMC5972770 DOI: 10.1089/apc.2018.0001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Current guidelines specify that visit intervals with viral monitoring should not exceed 6 months for HIV patients. Yet, gaps in care exceeding 6 months are common. In an observational cohort using US patients, we examined the association between gap length and changes in viral load status and sought to determine the length of the gap at which significant increases in viral load occur. We identified patients with gaps in care greater than 6 months from 6399 patients from six US HIV clinics. Gap strata were >6 to <7, 7 to <8, 8 to <9, 9 to <12, and ≥12 months, with viral load measurements matched to the opening and closing dates for the gaps. We examined visit gap lengths in association with two viral load measurements: continuous (log10 viral load at gap opening and closing) and dichotomous (whether patients initially suppressed but lost viral suppression by close of the care gap). Viral load increases were nonsignificant or modest when gap length was <9 months, corresponding to 10% or fewer patients who lost viral suppression. For gaps ≥12 months, there was a significant increase in viral load as well as a much larger loss of viral suppression (in 23% of patients). Detrimental effects on viral load after a care gap were greater in young patients, black patients, and those without private health insurance. On average, shorter gaps in care were not detrimental to patient viral load status. HIV primary care visit intervals of 6 to 9 months for select patients may be appropriate.
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Affiliation(s)
- Lytt I. Gardner
- Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Gary Marks
- Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Unnati Patel
- Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention and ICF, Atlanta, Georgia
| | - Edward Cachay
- Department of Medicine, University of California School of Medicine, San Diego, California
| | - Tracey E. Wilson
- Department of Community Health Sciences, School of Public Health, State University of New York, Downstate Medical Center, Brooklyn, New York
| | - Michael Stirratt
- Division of AIDS Research, National Institute of Mental Health, Bethesda, Maryland
| | - Allan Rodriguez
- Division of Infectious Diseases, Miller School of Medicine, University of Miami, Miami, Florida
| | - Meg Sullivan
- Department of Medicine, Boston University School of Medicine, Boston, Massachusetts
| | - Jeanne C. Keruly
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Thomas P. Giordano
- Department of Medicine, Baylor College of Medicine, Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey VA Medical Center, Thomas Street Health Center and Harris Health System, Houston, Texas
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31
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Monroe AK, Fleishman JA, Voss CC, Keruly JC, Nijhawan AE, Agwu AL, Aberg JA, Rutstein RM, Moore RD, Gebo KA. Assessing Antiretroviral Use During Gaps in HIV Primary Care Using Multisite Medicaid Claims and Clinical Data. J Acquir Immune Defic Syndr 2017; 76:82-89. [PMID: 28797023 DOI: 10.1097/qai.0000000000001469] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND Some individuals who appear poorly retained by clinic visit-based retention measures are using antiretroviral therapy (ART) and maintaining viral suppression. We examined whether individuals with a gap in HIV primary care (≥180 days between HIV outpatient clinic visits) obtained ART during that gap after 180 days. SETTING HIV Research Network data from 5 sites and Medicaid Analytic Extract eligibility and pharmacy data were combined. METHODS Factors associated with having both an HIV primary care gap and a new (ie, nonrefill) ART prescription during a gap were evaluated with multinomial logistic regression. RESULTS Of 6892 HIV Research Network patients, 6196 (90%) were linked to Medicaid data, and 4275 had any Medicaid ART prescription. Over half (54%) had occasional gaps in HIV primary care. Women, older people, and those with suppressed viral load were less likely to have a gap. Among those with occasional gaps (n = 2282), 51% received a new ART prescription in a gap. Viral load suppression before gap was associated with receiving a new ART prescription in a gap (odds ratio = 1.91, 95% confidence interval: 1.57 to 2.32), as was number of days in a gap (odds ratio = 1.04, 95% confidence interval: 1.02 to 1.05), and the proportion of months in the gap enrolled in Medicaid. CONCLUSIONS Medicaid-insured individuals commonly receive ART during gaps in HIV primary care, but almost half do not. Retention measures based on visit frequency data that do not incorporate receipt of ART and/or viral suppression may misclassify individuals who remain suppressed on ART as not retained.
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Affiliation(s)
- Anne K Monroe
- *Division of General Internal Medicine, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD;†Center for Financing, Access, and Cost Trends, Agency for Healthcare Research and Quality, Rockville, MD;‡Division of Infectious Diseases, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD;§Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX;‖Divisions of Adult and Pediatric Infectious Diseases, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD;¶Department of Medicine, Division of Infectious Diseases, Icahn School of Medicine at Mount Sinai, New York, NY; and#Division of General Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA
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Prodger JL, Lai J, Reynolds SJ, Keruly JC, Moore RD, Kasule J, Kityamuweesi T, Buule P, Serwadda D, Nason M, Capoferri AA, Porcella SF, Siliciano RF, Redd AD, Siliciano JD, Quinn TC. Reduced Frequency of Cells Latently Infected With Replication-Competent Human Immunodeficiency Virus-1 in Virally Suppressed Individuals Living in Rakai, Uganda. Clin Infect Dis 2017; 65:1308-1315. [PMID: 28535179 PMCID: PMC5850010 DOI: 10.1093/cid/cix478] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2017] [Accepted: 05/19/2017] [Indexed: 01/17/2023] Open
Abstract
Background Human immunodeficiency virus type 1 (HIV-1) persists in latently infected resting CD4+ T cells (rCD4 cells), posing a major barrier to curing HIV-1 infection. Previous studies have quantified this pool of latently infected cells in Americans; however, no study has quantified this reservoir in sub-Saharan Africans, who make up the largest population of HIV-1-infected individuals globally. Methods Peripheral blood was collected from 70 virally suppressed HIV-1-infected individuals from Rakai District, Uganda, who had initiated antiretroviral therapy (ART) during chronic infection. The quantitative viral outgrowth assay was used to determine frequency of latently infected rCD4 cells containing replication-competent virus. Multivariate regression was used to identify correlates of reservoir size and to compare reservoir size between this Ugandan cohort and a previously studied cohort of individuals from Baltimore, Maryland. Results The median frequency of latently infected rCD4 cells in this Ugandan cohort was 0.36 infectious units per million cells (IUPM; 95% confidence interval, 0.26-0.55 IUPM), 3-fold lower than the frequency observed in the Baltimore cohort (1.08 IUPM; .72-1.49 IUPM; P < .001). Reservoir size in Ugandans was correlated positively with set-point viral load and negatively with duration of viral suppression. Conclusions Virally suppressed Ugandans had a 3-fold lower frequency of rCD4 cells latently infected with replication-competent HIV-1, compared with previous observations in a cohort of American patients, also treated with ART during chronic infection. The biological mechanism driving the observed smaller reservoir in Ugandans is of interest and may be of significance to HIV-1 eradication efforts.
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Affiliation(s)
- Jessica L Prodger
- Laboratory of Immunoregulation, Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, and
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health and
| | - Jun Lai
- Division of Infectious Diseases, Johns Hopkins University School of Medicine,Baltimore, Maryland
| | - Steven J Reynolds
- Laboratory of Immunoregulation, Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, and
- Division of Infectious Diseases, Johns Hopkins University School of Medicine,Baltimore, Maryland
- Rakai Health Sciences Program, Kalisizo,Uganda
| | - Jeanne C Keruly
- Division of Infectious Diseases, Johns Hopkins University School of Medicine,Baltimore, Maryland
| | - Richard D Moore
- Department of Medicine, Johns Hopkins University, Baltimore, Maryland
| | | | | | - Paul Buule
- Rakai Health Sciences Program, Kalisizo,Uganda
| | - David Serwadda
- Rakai Health Sciences Program, Kalisizo,Uganda
- Makerere University, Kampala, Uganda
| | - Martha Nason
- Biostatistics Research Branch, Division of Clinical Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland
| | - Adam A Capoferri
- Division of Infectious Diseases, Johns Hopkins University School of Medicine,Baltimore, Maryland
| | - Stephen F Porcella
- Genomics Unit, Research Technologies Branch, Rocky Mountain Laboratories, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Hamilton, Montana; and
| | - Robert F Siliciano
- Division of Infectious Diseases, Johns Hopkins University School of Medicine,Baltimore, Maryland
- Howard Hughes Medical Institute, Baltimore, Maryland
| | - Andrew D Redd
- Laboratory of Immunoregulation, Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, and
- Division of Infectious Diseases, Johns Hopkins University School of Medicine,Baltimore, Maryland
| | - Janet D Siliciano
- Department of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Thomas C Quinn
- Laboratory of Immunoregulation, Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, and
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health and
- Division of Infectious Diseases, Johns Hopkins University School of Medicine,Baltimore, Maryland
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Wendel SK, Longosz AF, Eshleman SH, Blankson JN, Moore RD, Keruly JC, Quinn TC, Laeyendecker O. Short Communication: The Impact of Viral Suppression and Viral Breakthrough on Limited-Antigen Avidity Assay Results in Individuals with Clade B HIV Infection. AIDS Res Hum Retroviruses 2017; 33:325-327. [PMID: 27875908 DOI: 10.1089/aid.2016.0105] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
We analyzed the impact of HIV viral load on the performance of a limiting antigen avidity enzyme immunoassay (LAg-Avidity assay) and determined if this assay could be used to identify viral breakthrough. Three groups of samples were tested: (1) 18 individuals (30 samples) previously identified as elite suppressors; (2) 18 individuals (72 samples) who were continually suppressed on antiretroviral treatment (ART) with 1 sample before and 2-6 samples (one/year) after ART initiation; and (3) 20 individuals (179 samples) on ART who had evidence of viral breakthrough (>400 copies/ml) with subsequent viral suppression. Elite suppressors had the lowest LAg-Avidity assay values. Among those who were continually suppressed on ART, 83% (15/18) had LAg-Avidity assay values that decreased over time. Although the LAg-Avidity assay on a single sample cannot identify when a viral breakthrough occurs, paired longitudinal samples could identify viral breakthrough (sensitivity: 65%, specificity: 84%).
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Affiliation(s)
- Sarah K Wendel
- 1 Laboratory of Immunoregulation (LIR), National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH) , Baltimore, Maryland
| | - Andrew F Longosz
- 2 Department of Medicine, Johns Hopkins University School of Medicine , Baltimore, Maryland
| | - Susan H Eshleman
- 3 Department of Pathology, Johns Hopkins University School of Medicine , Baltimore, Maryland
| | - Joel N Blankson
- 2 Department of Medicine, Johns Hopkins University School of Medicine , Baltimore, Maryland
| | - Richard D Moore
- 2 Department of Medicine, Johns Hopkins University School of Medicine , Baltimore, Maryland
| | - Jeanne C Keruly
- 2 Department of Medicine, Johns Hopkins University School of Medicine , Baltimore, Maryland
| | - Thomas C Quinn
- 1 Laboratory of Immunoregulation (LIR), National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH) , Baltimore, Maryland
- 2 Department of Medicine, Johns Hopkins University School of Medicine , Baltimore, Maryland
| | - Oliver Laeyendecker
- 1 Laboratory of Immunoregulation (LIR), National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH) , Baltimore, Maryland
- 2 Department of Medicine, Johns Hopkins University School of Medicine , Baltimore, Maryland
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Agwu AL, Fleishman JA, Mahiane G, Nonyane BAS, Althoff KN, Yehia BR, Berry SA, Rutstein R, Nijhawan A, Mathews C, Aberg JA, Keruly JC, Moore RD, Gebo KA. Comparing longitudinal CD4 responses to cART among non-perinatally HIV-infected youth versus adults: Results from the HIVRN Cohort. PLoS One 2017; 12:e0171125. [PMID: 28182675 PMCID: PMC5300758 DOI: 10.1371/journal.pone.0171125] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2016] [Accepted: 01/15/2017] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Youth have residual thymic tissue and potentially greater capacity for immune reconstitution than adults after initiation of combination antiretroviral therapy (cART). However, youth face behavioral and psychosocial challenges that may make them more likely than adults to delay ART initiation and less likely to attain similar CD4 outcomes after initiating cART. This study compared CD4 outcomes over time following cART initiation between ART-naïve non-perinatally HIV-infected (nPHIV) youth (13-24 years-old) and adults (≥25-44 years-old). METHODS Retrospective analysis of ART-naïve nPHIV individuals 13-44 years-old, who initiated their first cART between 2008 and 2011 at clinical sites in the HIV Research Network. A linear mixed model was used to assess the association between CD4 levels after cART initiation and age (13-24, 25-34, 35-44 years), accounting for random variation within participants and between sites, and adjusting for key variables including gender, race/ethnicity, viral load, gaps in care (defined as > 365 days between CD4 tests), and CD4 levels prior to cART initiation (baseline CD4). RESULTS Among 2,595 individuals (435 youth; 2,160 adults), the median follow-up after cART initiation was 179 weeks (IQR 92-249). Baseline CD4 was higher for youth (320 cells/mm3) than for ages 25-34 (293) or 35-44 (258). At 239 weeks after cART initiation, median unadjusted CD4 was higher for youth than adults (576 vs. 539 and 476 cells/mm3, respectively), but this difference was not significant when baseline CD4 was controlled. Compared to those with baseline CD4 ≤200 cells/mm3, individuals with baseline CD4 of 201-500 and >500 cells/mm3 had greater predicted CD4 levels: 390, 607, and 831, respectively. Additionally, having no gaps in care and higher viral load were associated with better CD4 outcomes. CONCLUSIONS Despite having residual thymic tissue, youth attain similar, not superior, CD4 gains as adults. Early ART initiation with minimal delay is as essential to optimizing outcomes for youth as it is for their adult counterparts.
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Affiliation(s)
- Allison L. Agwu
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD, United States of America
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, United States of America
| | - John A. Fleishman
- Center for Financing, Access, and Cost Trends, Agency for Healthcare Research and Quality, Rockville, MD, United States of America
| | - Guy Mahiane
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States of America
| | - Bareng Aletta Sanny Nonyane
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States of America
| | - Keri N. Althoff
- Bloomberg School of Public Health, Johns Hopkins Medical Institutions, Baltimore, MD, United States of America
| | - Baligh R. Yehia
- Division of Infectious Diseases, Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia, PA, United States of America
| | - Stephen A. Berry
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, United States of America
| | - Richard Rutstein
- Division of General Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, PA, United States of America
| | - Ank Nijhawan
- Department of Internal Medicine, UT Southwestern Medical Center, Parkland Health and Hospital System, Dallas TX, United States of America
| | - Christopher Mathews
- Department of Medicine, University of California San Diego, San Diego, CA, United States of America
| | - Judith A. Aberg
- Department of Medicine, Division of Infectious Diseases, Icahn School of Medicine at Mount Sinai, New York, NY, United States of America
| | - Jeanne C. Keruly
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, United States of America
| | - Richard D. Moore
- Division of General Internal Medicine, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, United States of America
| | - Kelly A. Gebo
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, United States of America
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Lee L, Yehia BR, Gaur AH, Rutstein R, Gebo K, Keruly JC, Moore RD, Nijhawan AE, Agwu AL. The Impact of Youth-Friendly Structures of Care on Retention Among HIV-Infected Youth. AIDS Patient Care STDS 2016; 30:170-7. [PMID: 26983056 DOI: 10.1089/apc.2015.0263] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Limited data exist on how structures of care impact retention among youth living with HIV (YLHIV). We describe the availability of youth-friendly structures of care within HIV Research Network (HIVRN) clinics and examine their association with retention in HIV care. Data from 680 15- to 24-year-old YLHIV receiving care at 7 adult and 5 pediatric clinics in 2011 were included in the analysis. The primary outcome was retention in care, defined as completing ≥2 primary HIV care visits ≥90 days apart in a 12-month period. Sites were surveyed to assess the availability of clinic structures defined a priori as 'youth-friendly'. Univariate and multivariable logistic regression models assessed structures associated with retention in care. Among 680 YLHIV, 85% were retained. Nearly half (48%) of the 680 YLHIV attended clinics with youth-friendly waiting areas, 36% attended clinics with evening hours, 73% attended clinics with adolescent health-trained providers, 87% could email or text message providers, and 73% could schedule a routine appointment within 2 weeks. Adjusting for demographic and clinical factors, YLHIV were more likely to be retained in care at clinics with a youth-friendly waiting area (AOR 2.47, 95% CI [1.11-5.52]), evening clinic hours (AOR 1.94; 95% CI [1.13-3.33]), and providers with adolescent health training (AOR 1.98; 95% CI [1.01-3.86]). Youth-friendly structures of care impact retention in care among YLHIV. Further investigations are needed to determine how to effectively implement youth-friendly strategies across clinical settings where YLHIV receive care.
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Affiliation(s)
- Lana Lee
- Divisions of General Pediatrics and Adolescent Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Baligh R. Yehia
- Department of Infectious Diseases, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Aditya H. Gaur
- Department of Infectious Diseases, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Richard Rutstein
- Division of General Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Kelly Gebo
- Divisions of Infectious Diseases, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Jeanne C. Keruly
- Divisions of Infectious Diseases, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Richard D. Moore
- Divisions of Infectious Diseases, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Ank E. Nijhawan
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Allison L. Agwu
- Divisions of Adult and Pediatric Infectious Diseases, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
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Lai H, Moore R, Celentano DD, Gerstenblith G, Treisman G, Keruly JC, Kickler T, Li J, Chen S, Lai S, Fishman EK. HIV Infection Itself May Not Be Associated With Subclinical Coronary Artery Disease Among African Americans Without Cardiovascular Symptoms. J Am Heart Assoc 2016; 5:e002529. [PMID: 27013538 PMCID: PMC4943239 DOI: 10.1161/jaha.115.002529] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Background The key objectives of this study were to examine whether HIV infection itself is associated with subclinical coronary atherosclerosis and the potential contributions of cocaine use and antiretroviral therapies (ARTs) to subclinical coronary artery disease (CAD) in HIV‐infected persons. Methods and Results Between June 2004 and February 2015, 1429 African American (AA) adults with/without HIV infection in Baltimore, Maryland, were enrolled in an observational study of the effects of HIV infection, exposure to ART, and cocaine use on subclinical CAD. The prevalence of subclinical coronary atherosclerosis was 30.0% in HIV‐uninfected and 33.7% in HIV‐infected (P=0.17). Stratified analyses revealed that compared to HIV‐uninfected, HIV‐infected ART naïve were at significantly lower risk for subclinical coronary atherosclerosis, whereas HIV‐infected long‐term ART users (≥36 months) were at significantly higher risk. Thus, an overall nonsignificant association between subclinical coronary atherosclerosis and HIV was found. Furthermore, compared to those who were ART naïve, long‐term ART users (≥36 months) were at significantly higher risk for subclinical coronary atherosclerosis in chronic cocaine users, but not in those who never used cocaine. Cocaine use was independently associated with subclinical coronary atherosclerosis. Conclusions Overall, HIV infection, per se, was not associated with subclinical coronary atherosclerosis in this population. Cocaine use was prevalent in both HIV‐infected and ‐uninfected individuals and itself was associated with subclinical disease. In addition, cocaine significantly elevated the risk for ART‐associated subclinical coronary atherosclerosis. Treating cocaine addiction must be a high priority for managing HIV disease and preventing HIV/ART‐associated subclinical and clinical CAD in individuals with HIV infection.
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Affiliation(s)
- Hong Lai
- Department of Radiology, Johns Hopkins School of Medicine, Baltimore, MD
| | - Richard Moore
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD
| | - David D Celentano
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Gary Gerstenblith
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD
| | - Glenn Treisman
- Department of Psychiatry, Johns Hopkins School of Medicine, Baltimore, MD
| | - Jeanne C Keruly
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD
| | - Thomas Kickler
- Department of Pathology, Johns Hopkins School of Medicine, Baltimore, MD
| | - Ji Li
- Department of Pathology, Johns Hopkins School of Medicine, Baltimore, MD
| | - Shaoguang Chen
- Department of Pathology, Johns Hopkins School of Medicine, Baltimore, MD
| | - Shenghan Lai
- Department of Radiology, Johns Hopkins School of Medicine, Baltimore, MD Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD Department of Psychiatry, Johns Hopkins School of Medicine, Baltimore, MD Department of Pathology, Johns Hopkins School of Medicine, Baltimore, MD Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Elliot K Fishman
- Department of Radiology, Johns Hopkins School of Medicine, Baltimore, MD
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Zinski A, Westfall AO, Gardner LI, Giordano TP, Wilson TE, Drainoni ML, Keruly JC, Rodriguez AE, Malitz F, Batey DS, Mugavero MJ. The Contribution of Missed Clinic Visits to Disparities in HIV Viral Load Outcomes. Am J Public Health 2015; 105:2068-75. [PMID: 26270301 DOI: 10.2105/ajph.2015.302695] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES We explored the contribution of missed primary HIV care visits ("no-show") to observed disparities in virological failure (VF) among Black persons and persons with injection drug use (IDU) history. METHODS We used patient-level data from 6 academic clinics, before the Centers for Disease Control and Prevention and Health Resources and Services Administration Retention in Care intervention. We employed staged multivariable logistic regression and multivariable models stratified by no-show visit frequency to evaluate the association of sociodemographic factors with VF. We used multiple imputations to assign missing viral load values. RESULTS Among 10 053 patients (mean age = 46 years; 35% female; 64% Black; 15% with IDU history), 31% experienced VF. Although Black patients and patients with IDU history were significantly more likely to experience VF in initial analyses, race and IDU parameter estimates were attenuated after sequential addition of no-show frequency. In stratified models, race and IDU were not statistically significantly associated with VF at any no-show level. CONCLUSIONS Because missed clinic visits contributed to observed differences in viral load outcomes among Black and IDU patients, achieving an improved understanding of differential visit attendance is imperative to reducing disparities in HIV.
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Affiliation(s)
- Anne Zinski
- Anne Zinski, Andrew O. Westfall, D. Scott Batey, and Michael J. Mugavero are with the Department of Medicine, Division of Infectious Diseases, University of Alabama at Birmingham. Lytt I. Gardner is with the Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, GA. Thomas P. Giordano is with the Department of Medicine, Section of Infectious Diseases, Baylor College of Medicine, Houston, TX. Tracey E. Wilson is with the Department of Community Health Sciences, State University of New York, Downstate Medical Center, Brooklyn, NY. Mari-Lynn Drainoni is with the Department of Health Policy and Management, Boston University School of Public Health, Boston, MA. Jeanne C. Keruly is with Johns Hopkins University, School of Medicine, Division of Infectious Diseases, Baltimore, MD. Allan E. Rodriguez is with the Division of Infectious Diseases, Miller School of Medicine, University of Miami, FL. Faye Malitz is with the HIV/AIDS Bureau, Health Resources and Services Administration, Rockville, MD
| | - Andrew O Westfall
- Anne Zinski, Andrew O. Westfall, D. Scott Batey, and Michael J. Mugavero are with the Department of Medicine, Division of Infectious Diseases, University of Alabama at Birmingham. Lytt I. Gardner is with the Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, GA. Thomas P. Giordano is with the Department of Medicine, Section of Infectious Diseases, Baylor College of Medicine, Houston, TX. Tracey E. Wilson is with the Department of Community Health Sciences, State University of New York, Downstate Medical Center, Brooklyn, NY. Mari-Lynn Drainoni is with the Department of Health Policy and Management, Boston University School of Public Health, Boston, MA. Jeanne C. Keruly is with Johns Hopkins University, School of Medicine, Division of Infectious Diseases, Baltimore, MD. Allan E. Rodriguez is with the Division of Infectious Diseases, Miller School of Medicine, University of Miami, FL. Faye Malitz is with the HIV/AIDS Bureau, Health Resources and Services Administration, Rockville, MD
| | - Lytt I Gardner
- Anne Zinski, Andrew O. Westfall, D. Scott Batey, and Michael J. Mugavero are with the Department of Medicine, Division of Infectious Diseases, University of Alabama at Birmingham. Lytt I. Gardner is with the Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, GA. Thomas P. Giordano is with the Department of Medicine, Section of Infectious Diseases, Baylor College of Medicine, Houston, TX. Tracey E. Wilson is with the Department of Community Health Sciences, State University of New York, Downstate Medical Center, Brooklyn, NY. Mari-Lynn Drainoni is with the Department of Health Policy and Management, Boston University School of Public Health, Boston, MA. Jeanne C. Keruly is with Johns Hopkins University, School of Medicine, Division of Infectious Diseases, Baltimore, MD. Allan E. Rodriguez is with the Division of Infectious Diseases, Miller School of Medicine, University of Miami, FL. Faye Malitz is with the HIV/AIDS Bureau, Health Resources and Services Administration, Rockville, MD
| | - Thomas P Giordano
- Anne Zinski, Andrew O. Westfall, D. Scott Batey, and Michael J. Mugavero are with the Department of Medicine, Division of Infectious Diseases, University of Alabama at Birmingham. Lytt I. Gardner is with the Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, GA. Thomas P. Giordano is with the Department of Medicine, Section of Infectious Diseases, Baylor College of Medicine, Houston, TX. Tracey E. Wilson is with the Department of Community Health Sciences, State University of New York, Downstate Medical Center, Brooklyn, NY. Mari-Lynn Drainoni is with the Department of Health Policy and Management, Boston University School of Public Health, Boston, MA. Jeanne C. Keruly is with Johns Hopkins University, School of Medicine, Division of Infectious Diseases, Baltimore, MD. Allan E. Rodriguez is with the Division of Infectious Diseases, Miller School of Medicine, University of Miami, FL. Faye Malitz is with the HIV/AIDS Bureau, Health Resources and Services Administration, Rockville, MD
| | - Tracey E Wilson
- Anne Zinski, Andrew O. Westfall, D. Scott Batey, and Michael J. Mugavero are with the Department of Medicine, Division of Infectious Diseases, University of Alabama at Birmingham. Lytt I. Gardner is with the Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, GA. Thomas P. Giordano is with the Department of Medicine, Section of Infectious Diseases, Baylor College of Medicine, Houston, TX. Tracey E. Wilson is with the Department of Community Health Sciences, State University of New York, Downstate Medical Center, Brooklyn, NY. Mari-Lynn Drainoni is with the Department of Health Policy and Management, Boston University School of Public Health, Boston, MA. Jeanne C. Keruly is with Johns Hopkins University, School of Medicine, Division of Infectious Diseases, Baltimore, MD. Allan E. Rodriguez is with the Division of Infectious Diseases, Miller School of Medicine, University of Miami, FL. Faye Malitz is with the HIV/AIDS Bureau, Health Resources and Services Administration, Rockville, MD
| | - Mari-Lynn Drainoni
- Anne Zinski, Andrew O. Westfall, D. Scott Batey, and Michael J. Mugavero are with the Department of Medicine, Division of Infectious Diseases, University of Alabama at Birmingham. Lytt I. Gardner is with the Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, GA. Thomas P. Giordano is with the Department of Medicine, Section of Infectious Diseases, Baylor College of Medicine, Houston, TX. Tracey E. Wilson is with the Department of Community Health Sciences, State University of New York, Downstate Medical Center, Brooklyn, NY. Mari-Lynn Drainoni is with the Department of Health Policy and Management, Boston University School of Public Health, Boston, MA. Jeanne C. Keruly is with Johns Hopkins University, School of Medicine, Division of Infectious Diseases, Baltimore, MD. Allan E. Rodriguez is with the Division of Infectious Diseases, Miller School of Medicine, University of Miami, FL. Faye Malitz is with the HIV/AIDS Bureau, Health Resources and Services Administration, Rockville, MD
| | - Jeanne C Keruly
- Anne Zinski, Andrew O. Westfall, D. Scott Batey, and Michael J. Mugavero are with the Department of Medicine, Division of Infectious Diseases, University of Alabama at Birmingham. Lytt I. Gardner is with the Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, GA. Thomas P. Giordano is with the Department of Medicine, Section of Infectious Diseases, Baylor College of Medicine, Houston, TX. Tracey E. Wilson is with the Department of Community Health Sciences, State University of New York, Downstate Medical Center, Brooklyn, NY. Mari-Lynn Drainoni is with the Department of Health Policy and Management, Boston University School of Public Health, Boston, MA. Jeanne C. Keruly is with Johns Hopkins University, School of Medicine, Division of Infectious Diseases, Baltimore, MD. Allan E. Rodriguez is with the Division of Infectious Diseases, Miller School of Medicine, University of Miami, FL. Faye Malitz is with the HIV/AIDS Bureau, Health Resources and Services Administration, Rockville, MD
| | - Allan E Rodriguez
- Anne Zinski, Andrew O. Westfall, D. Scott Batey, and Michael J. Mugavero are with the Department of Medicine, Division of Infectious Diseases, University of Alabama at Birmingham. Lytt I. Gardner is with the Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, GA. Thomas P. Giordano is with the Department of Medicine, Section of Infectious Diseases, Baylor College of Medicine, Houston, TX. Tracey E. Wilson is with the Department of Community Health Sciences, State University of New York, Downstate Medical Center, Brooklyn, NY. Mari-Lynn Drainoni is with the Department of Health Policy and Management, Boston University School of Public Health, Boston, MA. Jeanne C. Keruly is with Johns Hopkins University, School of Medicine, Division of Infectious Diseases, Baltimore, MD. Allan E. Rodriguez is with the Division of Infectious Diseases, Miller School of Medicine, University of Miami, FL. Faye Malitz is with the HIV/AIDS Bureau, Health Resources and Services Administration, Rockville, MD
| | - Faye Malitz
- Anne Zinski, Andrew O. Westfall, D. Scott Batey, and Michael J. Mugavero are with the Department of Medicine, Division of Infectious Diseases, University of Alabama at Birmingham. Lytt I. Gardner is with the Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, GA. Thomas P. Giordano is with the Department of Medicine, Section of Infectious Diseases, Baylor College of Medicine, Houston, TX. Tracey E. Wilson is with the Department of Community Health Sciences, State University of New York, Downstate Medical Center, Brooklyn, NY. Mari-Lynn Drainoni is with the Department of Health Policy and Management, Boston University School of Public Health, Boston, MA. Jeanne C. Keruly is with Johns Hopkins University, School of Medicine, Division of Infectious Diseases, Baltimore, MD. Allan E. Rodriguez is with the Division of Infectious Diseases, Miller School of Medicine, University of Miami, FL. Faye Malitz is with the HIV/AIDS Bureau, Health Resources and Services Administration, Rockville, MD
| | - D Scott Batey
- Anne Zinski, Andrew O. Westfall, D. Scott Batey, and Michael J. Mugavero are with the Department of Medicine, Division of Infectious Diseases, University of Alabama at Birmingham. Lytt I. Gardner is with the Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, GA. Thomas P. Giordano is with the Department of Medicine, Section of Infectious Diseases, Baylor College of Medicine, Houston, TX. Tracey E. Wilson is with the Department of Community Health Sciences, State University of New York, Downstate Medical Center, Brooklyn, NY. Mari-Lynn Drainoni is with the Department of Health Policy and Management, Boston University School of Public Health, Boston, MA. Jeanne C. Keruly is with Johns Hopkins University, School of Medicine, Division of Infectious Diseases, Baltimore, MD. Allan E. Rodriguez is with the Division of Infectious Diseases, Miller School of Medicine, University of Miami, FL. Faye Malitz is with the HIV/AIDS Bureau, Health Resources and Services Administration, Rockville, MD
| | - Michael J Mugavero
- Anne Zinski, Andrew O. Westfall, D. Scott Batey, and Michael J. Mugavero are with the Department of Medicine, Division of Infectious Diseases, University of Alabama at Birmingham. Lytt I. Gardner is with the Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, GA. Thomas P. Giordano is with the Department of Medicine, Section of Infectious Diseases, Baylor College of Medicine, Houston, TX. Tracey E. Wilson is with the Department of Community Health Sciences, State University of New York, Downstate Medical Center, Brooklyn, NY. Mari-Lynn Drainoni is with the Department of Health Policy and Management, Boston University School of Public Health, Boston, MA. Jeanne C. Keruly is with Johns Hopkins University, School of Medicine, Division of Infectious Diseases, Baltimore, MD. Allan E. Rodriguez is with the Division of Infectious Diseases, Miller School of Medicine, University of Miami, FL. Faye Malitz is with the HIV/AIDS Bureau, Health Resources and Services Administration, Rockville, MD
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Mugavero MJ, Westfall AO, Cole SR, Geng EH, Crane HM, Kitahata MM, Mathews WC, Napravnik S, Eron JJ, Moore RD, Keruly JC, Mayer KH, Giordano TP, Raper JL. Beyond core indicators of retention in HIV care: missed clinic visits are independently associated with all-cause mortality. Clin Infect Dis 2014; 59:1471-9. [PMID: 25091306 PMCID: PMC4215067 DOI: 10.1093/cid/ciu603] [Citation(s) in RCA: 123] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2014] [Accepted: 06/30/2014] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND The continuum of care is at the forefront of the domestic human immunodeficiency virus (HIV) agenda, with the Institute of Medicine (IOM) and Department of Health and Human Services (DHHS) recently releasing clinical core indicators. Core indicators for retention in care are calculated based on attended HIV care clinic visits. Beyond these retention core indicators, we evaluated the additional prognostic value of missed clinic visits for all-cause mortality. METHODS We conducted a multisite cohort study of 3672 antiretroviral-naive patients initiating antiretroviral therapy (ART) during 2000-2010. Retention in care was measured by the IOM and DHHS core indicators (2 attended visits at defined intervals per 12-month period), and also as a count of missed primary HIV care visits (no show) during a 24-month measurement period following ART initiation. All-cause mortality was ascertained by query of the Social Security Death Index and/or National Death Index, with adjusted survival analyses starting at 24 months after ART initiation. RESULTS Among participants, 64% and 59% met the IOM and DHHS retention core indicators, respectively, at 24 months. Subsequently, 332 patients died during 16 102 person-years of follow-up. Failure to achieve the IOM and DHHS indicators through 24 months following ART initiation increased mortality (hazard ratio [HR] = 2.23; 95% confidence interval [CI], 1.79-2.80 and HR = 2.36; 95% CI, 1.89-2.96, respectively). Among patients classified as retained by the IOM or DHHS clinical core indicators, >2 missed visits further increased mortality risk (HR = 3.61; 95% CI, 2.35-5.55 and HR = 3.62; 95% CI, 2.30-5.68, respectively). CONCLUSIONS Beyond HIV retention core indicators, missed clinic visits were independently associated with all-cause mortality. Caution is warranted in relying solely upon retention in care core indicators for policy, clinical, and programmatic purposes.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | - Kenneth H. Mayer
- Fenway Community Health Center, Boston, and
- Harvard University, Cambridge, Massachusetts and
| | - Thomas P. Giordano
- Michael E. DeBakey Veterans Affairs Medical Center
- Baylor College of Medicine, Houston, Texas
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Gardner LI, Giordano TP, Marks G, Wilson TE, Craw JA, Drainoni ML, Keruly JC, Rodriguez AE, Malitz F, Moore RD, Bradley-Springer LA, Holman S, Rose CE, Girde S, Sullivan M, Metsch LR, Saag M, Mugavero MJ. Enhanced personal contact with HIV patients improves retention in primary care: a randomized trial in 6 US HIV clinics. Clin Infect Dis 2014; 59:725-34. [PMID: 24837481 DOI: 10.1093/cid/ciu357] [Citation(s) in RCA: 121] [Impact Index Per Article: 12.1] [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: 11/13/2022] Open
Abstract
BACKGROUND The aim of the study was to determine whether enhanced personal contact with human immunodeficiency virus (HIV)-infected patients across time improves retention in care compared with existing standard of care (SOC) practices, and whether brief skills training improves retention beyond enhanced contact. METHODS The study, conducted at 6 HIV clinics in the United States, included 1838 patients with a recent history of inconsistent clinic attendance, and new patients. Each clinic randomized participants to 1 of 3 arms and continued to provide SOC practices to all enrollees: enhanced contact with interventionist (EC) (brief face-to-face meeting upon returning for care visit, interim visit call, appointment reminder calls, missed visit call); EC + skills (organization, problem solving, and communication skills); or SOC only. The intervention was delivered by project staff for 12 months following randomization. The outcomes during that 12-month period were (1) percentage of participants attending at least 1 primary care visit in 3 consecutive 4-month intervals (visit constancy), and (2) proportion of kept/scheduled primary care visits (visit adherence). RESULTS Log-binomial risk ratios comparing intervention arms against the SOC arm demonstrated better outcomes in both the EC and EC + skills arms (visit constancy: risk ratio [RR], 1.22 [95% confidence interval {CI}, 1.09-1.36] and 1.22 [95% CI, 1.09-1.36], respectively; visit adherence: RR, 1.08 [95% CI, 1.05-1.11] and 1.06 [95% CI, 1.02-1.09], respectively; all Ps < .01). Intervention effects were observed in numerous patient subgroups, although they were lower in patients reporting unmet needs or illicit drug use. CONCLUSIONS Enhanced contact with patients improved retention in HIV primary care compared with existing SOC practices. A brief patient skill-building component did not improve retention further. Additional intervention elements may be needed for patients reporting illicit drug use or who have unmet needs. CLINICAL TRIALS REGISTRATION CDCHRSA9272007.
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Affiliation(s)
- Lytt I Gardner
- Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Thomas P Giordano
- Department of Medicine, Baylor College of Medicine, and the Center for Innovations in Quality, Effectiveness and Safety, Michael. E. DeBakey Veterans Affairs Medical Center, Houston, Texas
| | - Gary Marks
- Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Tracey E Wilson
- Department of Community Health Sciences, State University of New York (SUNY) Downstate Medical Center School of Public Health, Brooklyn
| | - Jason A Craw
- Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Mari-Lynn Drainoni
- Department of Health Policy & Management, Boston University School of Public Health Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial VA Hospital Department of Medicine, Boston University School of Medicine, Boston, Massachusetts
| | - Jeanne C Keruly
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Allan E Rodriguez
- Division of Infectious Diseases, Miller School of Medicine, University of Miami, Florida
| | - Faye Malitz
- HIV/AIDS Bureau, Health Resources and Services Administration, Rockville, Maryland
| | - Richard D Moore
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | - Susan Holman
- Colleges of Medicine and Nursing, SUNY Downstate Medical Center, Brooklyn, New York
| | - Charles E Rose
- Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Sonali Girde
- Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia ICF International, Inc, Atlanta, Georgia
| | - Meg Sullivan
- Department of Medicine, Boston University School of Medicine, Boston, Massachusetts
| | - Lisa R Metsch
- Department of Epidemiology and Public Health, University of Miami, Florida
| | - Michael Saag
- 1917 HIV/AIDS Clinic and Department of Medicine, University of Alabama at Birmingham
| | - Michael J Mugavero
- 1917 HIV/AIDS Clinic and Department of Medicine, University of Alabama at Birmingham
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Lai H, Fishman EK, Gerstenblith G, Moore R, Brinker JA, Keruly JC, Chen S, Detrick B, Lai S. Vitamin D deficiency is associated with development of subclinical coronary artery disease in HIV-infected African American cocaine users with low Framingham-defined cardiovascular risk. Vasc Health Risk Manag 2013; 9:729-37. [PMID: 24265555 PMCID: PMC3833705 DOI: 10.2147/vhrm.s50537] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
UNLABELLED Chronic cocaine use may lead to premature atherosclerosis, but the prevalence of and risk factors for coronary artery disease (CAD) in asymptomatic cocaine users have not been reported. The objective of this study was to examine whether vitamin D deficiency is associated with the development of CAD in human immunodeficiency virus (HIV)-infected African American cocaine users with low CAD risk. METHODS In this prospective follow-up study, we investigated 169 HIV-infected African American cocaine users with low Framingham risk at baseline. The main outcome measures were incidence of subclinical CAD and development of subclinical CAD. RESULTS Fifty of the 169 African Americans had evidence of subclinical disease on the initial cardiac computed tomography. A second cardiac computed tomography was performed on the 119 African Americans without disease on the first scan. The total sum of person-years of follow-up was 289.6. Subclinical CAD was detected in 11 of these, yielding an overall incidence of 3.80/100 person-years (95% confidence interval 1.90-6.80). Among the factors investigated, only vitamin D deficiency was independently associated with development of subclinical CAD. The study did not find significant associations between CD4 count, HIV viral load, or antiretroviral treatment use and the incidence of subclinical CAD. This study appears to suggest that there is a threshold level of vitamin D (10 ng/mL) above which the effect of vitamin D on subclinical CAD is diminished. CONCLUSION The incidence of subclinical CAD in HIV-infected African American cocaine users with low CAD risk is high, especially in those with vitamin D deficiency. Well designed randomized clinical trials are warranted to confirm the role of vitamin D deficiency in the development of CAD in HIV-infected African American cocaine users with low CAD risk.
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Affiliation(s)
- Hong Lai
- Department of Radiology, Johns Hopkins School of Medicine, Baltimore, MD, USA
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Wendel SK, Mullis CE, Eshleman SH, Blankson JN, Moore RD, Keruly JC, Brookmeyer R, Quinn TC, Laeyendecker O. Effect of natural and ARV-induced viral suppression and viral breakthrough on anti-HIV antibody proportion and avidity in patients with HIV-1 subtype B infection. PLoS One 2013; 8:e55525. [PMID: 23437058 PMCID: PMC3577851 DOI: 10.1371/journal.pone.0055525] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2012] [Accepted: 12/27/2012] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Viral suppression and viral breakthrough impact the humoral immune response to HIV infection. We evaluated the impact of viral suppression and viral breakthrough on results obtained with two cross-sectional HIV incidence assays. METHODS All samples were collected from adults in the US who were HIV infected for >2 years. Samples were tested with the BED capture enzyme immunoassay (BED-CEIA) which measures the proportion of IgG that is HIV-specific, and with an antibody avidity assay based on the Genetic Systems 1/2+ O ELISA. We tested 281 samples: (1) 30 samples from 18 patients with natural control of HIV-1 infection known as elite controllers or suppressors (2) 72 samples from 18 adults on antiretroviral therapy (ART), with 1 sample before and 2-6 samples after ART initiation, and (3) 179 samples from 20 virally-suppressed adults who had evidence of viral breakthrough receiving ART (>400 copies/ml HIV RNA) and with subsequent viral suppression. RESULTS For elite suppressors, 10/18 had BED-CEIA values <0.8 normalized optical density units (OD-n) and these values did not change significantly over time. For patients receiving ART, 14/18 had BED-CEIA values that decreased over time, with a median decrease of 0.42 OD-n (range 0.10 to 0.63)/time point receiving ART. Three patterns of BED-CEIA values were observed during viral breakthrough: (1) values that increased then returned to pre-breakthrough values when viral suppression was re-established, (2) values that increased after viral breakthrough, and (3) values that did not change with viral breakthrough. CONCLUSIONS Viral suppression and viral breakthrough were associated with changes in BED-CEIA values, reflecting changes in the proportion of HIV-specific IgG. These changes can result in misclassification of patients with long-term HIV infection as recently infected using the BED-CEIA, thereby influencing a falsely high value for cross-sectional incidence estimates.
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Affiliation(s)
- Sarah K. Wendel
- Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Baltimore, Maryland, United States of America
| | - Caroline E. Mullis
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
| | - Susan H. Eshleman
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
| | - Joel N. Blankson
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
| | - Richard D. Moore
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
| | - Jeanne C. Keruly
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
| | - Ron Brookmeyer
- Department of Biostatistics, School of Public Health, University of California Los Angeles, Los Angeles, California, United States of America
| | - Thomas C. Quinn
- Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Baltimore, Maryland, United States of America
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
| | - Oliver Laeyendecker
- Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Baltimore, Maryland, United States of America
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
- * E-mail:
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Abstract
BACKGROUND Despite advances in human immunodeficiency virus (HIV) treatment, major challenges remain in achieving access, retention, and adherence. Our inner-city HIV clinical practice in Baltimore has a diverse patient population with high rates of poverty, black race, and injection drug use (IDU), providing us the opportunity to compare health process and outcomes. METHODS Using data collected in a clinical HIV cohort in Baltimore, we compared receipt of combination antiretroviral therapy (ART), HIV type 1 (HIV-1) RNA, CD4, incidence of opportunistic illness, and mortality from 1995 to 2010. Comparisons were made of these outcomes by HIV risk group, sex, and race (black, white). RESULTS From 1995 to 2010, we followed 6366 patients comprising 27 941 person-years (PY) of follow-up. By 2010, 87% of patients were receiving ART; median HIV-1 RNA was <200 copies/mL, median CD4 was 475 cells/mm(3), opportunistic illness rates were 2.4 per 100 PY, and mortality rates were 2.1 per 100 PY, with no differences by demographic or HIV risk group. The only differences were that the IDU risk group had a median CD4 that was 79 cells/mm(3) lower and HIV-1 RNA 0.16 log(10 )copies/mL higher compared with other risk groups (P < .01). In 2009 a 28-year-old HIV-infected person was estimated to have 45.4 years of life remaining, which did not differ by demographic or behavioral risk group. DISCUSSION Our results emphasize that advances in HIV treatment have had a positive impact on all affected demographic and behavioral risk groups in an HIV clinical setting, with an expected longevity for HIV-infected patients that is now 73 years.
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Affiliation(s)
- Richard D Moore
- Department of Medicine, Johns Hopkins University School of Medicine, 1830 E Monument St, Baltimore, MD 21287, USA.
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Gardner LI, Marks G, Craw JA, Wilson TE, Drainoni ML, Moore RD, Mugavero MJ, Rodriguez AE, Bradley-Springer LA, Holman S, Keruly JC, Sullivan M, Skolnik PR, Malitz F, Metsch LR, Raper JL, Giordano TP. A low-effort, clinic-wide intervention improves attendance for HIV primary care. Clin Infect Dis 2012; 55:1124-34. [PMID: 22828593 DOI: 10.1093/cid/cis623] [Citation(s) in RCA: 69] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Retention in care for human immunodeficiency virus (HIV)-infected patients is a National HIV/AIDS Strategy priority. We hypothesized that retention could be improved with coordinated messages to encourage patients' clinic attendance. We report here the results of the first phase of the Centers for Disease Control and Prevention/Health Resources and Services Administration Retention in Care project. METHODS Six HIV-specialty clinics participated in a cross-sectionally sampled pretest-posttest evaluation of brochures, posters, and messages that conveyed the importance of regular clinic attendance. 10,018 patients in 2008-2009 (preintervention period) and 11,039 patients in 2009-2010 (intervention period) were followed up for clinic attendance. Outcome variables were the percentage of patients who kept 2 consecutive primary care visits and the mean proportion of all primary care visits kept. Stratification variables were: new, reengaging, and active patients, HIV RNA viral load, CD4 cell count, age, sex, race or ethnicity, risk group, number of scheduled visits, and clinic site. Data were analyzed by multivariable log-binomial and linear models using generalized estimation equation methods. RESULTS Clinic attendance for primary care was significantly higher in the intervention versus preintervention year. Overall relative improvement was 7.0% for keeping 2 consecutive visits and 3.0% for the mean proportion of all visits kept (P < .0001). Larger relative improvement for both outcomes was observed for new or reengaging patients, young patients and patients with elevated viral loads. Improved attendance among the new or reengaging patients was consistent across the 6 clinics, and less consistent across clinics for active patients. CONCLUSION Targeted messages on staying in care, which were delivered at minimal effort and cost, improved clinic attendance, especially for new or reengaging patients, young patients, and those with elevated viral loads.
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Affiliation(s)
- Lytt I Gardner
- Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, GA 30333, USA.
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Marks G, Gardner LI, Craw J, Giordano TP, Mugavero MJ, Keruly JC, Wilson TE, Metsch LR, Drainoni ML, Malitz F. The spectrum of engagement in HIV care: do more than 19% of HIV-infected persons in the US have undetectable viral load? Clin Infect Dis 2011; 53:1168-9; author's reply 1169-70. [PMID: 21976466 DOI: 10.1093/cid/cir678] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Lucas GM, Chaudhry A, Hsu J, Woodson T, Lau B, Olsen Y, Keruly JC, Fiellin DA, Finkelstein R, Barditch-Crovo P, Cook K, Moore RD. Clinic-based treatment of opioid-dependent HIV-infected patients versus referral to an opioid treatment program: A randomized trial. Ann Intern Med 2010; 152:704-11. [PMID: 20513828 PMCID: PMC2886293 DOI: 10.7326/0003-4819-152-11-201006010-00003] [Citation(s) in RCA: 87] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Opioid dependence is common in HIV clinics. Buprenorphine-naloxone (BUP) is an effective treatment of opioid dependence that may be used in routine medical settings. OBJECTIVE To compare clinic-based treatment with BUP (clinic-based BUP) with case management and referral to an opioid treatment program (referred treatment). DESIGN Single-center, 12-month randomized trial. Participants and investigators were aware of treatment assignments. (ClinicalTrials.gov registration number: NCT00130819) SETTING HIV clinic in Baltimore, Maryland. PATIENTS 93 HIV-infected, opioid-dependent participants who were not receiving opioid agonist therapy and were not dependent on alcohol or benzodiazepines. INTERVENTION Clinic-based BUP included BUP induction and dose titration, urine drug testing, and individual counseling. Referred treatment included case management and referral to an opioid-treatment program. MEASUREMENTS Initiation and long-term receipt of opioid agonist therapy, urine drug test results, visit attendance with primary HIV care providers, use of antiretroviral therapy, and changes in HIV RNA levels and CD4 cell counts. RESULTS The average estimated participation in opioid agonist therapy was 74% (95% CI, 61% to 84%) for clinic-based BUP and 41% (CI, 29% to 53%) for referred treatment (P < 0.001). Positive test results for opioids and cocaine were significantly less frequent in clinic-based BUP than in referred treatment, and study participants receiving clinic-based BUP attended significantly more HIV primary care visits than those receiving referred treatment. Use of antiretroviral therapy and changes in HIV RNA levels and CD4 cell counts did not differ between the 2 groups. LIMITATION This was a small single-center study, follow-up was only moderate, and the study groups were unbalanced in terms of recent drug injections at baseline. CONCLUSION Management of HIV-infected, opioid-dependent patients with a clinic-based BUP strategy facilitates access to opioid agonist therapy and improves outcomes of substance abuse treatment. PRIMARY FUNDING SOURCE Health Resources and Services Administration Special Projects of National Significance program.
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Affiliation(s)
- Gregory M Lucas
- Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
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Redd AD, Ciccone EJ, Nakigozi G, Keruly JC, Ndyanabo A, Iga B, Gray RH, Serwadda D, Quinn TC. T-cell enumeration from dried blood spots by quantifying rearranged T-cell receptor-beta genes. J Immunol Methods 2010; 354:40-4. [PMID: 20109463 PMCID: PMC2844472 DOI: 10.1016/j.jim.2010.01.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [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] [Received: 11/05/2009] [Revised: 01/14/2010] [Accepted: 01/19/2010] [Indexed: 11/30/2022]
Abstract
Significant hurdles remain to large-scale implementation of medical interventions in the developing world due to the lack of a modern diagnostic infrastructure. This is especially pertinent to the international roll-out of antiretroviral drugs to treat HIV, which ideally includes a CD4 T-cell count to determine eligibility. We designed a novel technique to estimate mature T-cell numbers by calculating the amount of rearranged T-cell receptor beta genes from dried blood spots of HIV-infected individuals in the United States and Uganda. It was observed that the rearranged T-cell receptor beta count correlated well with total lymphocyte counts from both study populations (Baltimore R=0.602, Uganda R=0.497; p<0.001) and the ability for this measurement to determine antiretroviral initiation was similar to total lymphocyte counts, which can be used to determine eligibility in HIV+children. This technique as well as other dried blood spot based technologies could increase the diagnostic and monitoring capabilities in resource-limited settings.
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Affiliation(s)
- Andrew D Redd
- Laboratory of Immunoregulation, Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA.
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Moore RD, Gebo KA, Lucas GM, Keruly JC. Rate of comorbidities not related to HIV infection or AIDS among HIV-infected patients, by CD4 cell count and HAART use status. Clin Infect Dis 2008; 47:1102-4. [PMID: 18781885 DOI: 10.1086/592115] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
The rate of comorbidities not related to human immunodeficiency virus (HIV) infection or acquired immunodeficiency syndrome (AIDS) among HIV-infected patients may be higher than expected. We assessed the incidence of comorbidities not related to HIV infection or AIDS by CD4 cell count and highly active antiretroviral therapy (HAART) use status in an HIV clinical practice. A total of 2824 patients contributed 9172 person-years of longitudinal data during the period 1997-2006. Among patients with a CD4 cell count <350 cells/mm(3), receipt of HAART was associated with a significantly decreased incidence of comorbidities not related to HIV infection or AIDS.
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Affiliation(s)
- Richard D Moore
- Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
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Keruly JC, Moore RD. Immune status at presentation to care did not improve among antiretroviral-naive persons from 1990 to 2006. Clin Infect Dis 2007; 45:1369-74. [PMID: 17968837 DOI: 10.1086/522759] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2007] [Accepted: 07/17/2007] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Human immunodeficiency virus (HIV) prevention initiatives to improve access to HIV services have increased over time. Despite this, >250,000 cases of HIV infection in the United States are undiagnosed, and many infected persons do not present for care until their HIV infection is advanced. Late presentation may increase the risk of HIV transmission and make HIV infection more difficult to treat effectively. With more effective HIV therapy, it was hoped that patients might present earlier in their disease course. METHODS To assess immune status and time of HIV diagnosis in patients who newly presented for care, we analyzed data for the period 1990-2006 from patients who were antiretroviral naive at presentation to the Johns Hopkins HIV Clinic in Baltimore, Maryland. We compared CD4(+) cell count and time from HIV diagnosis at presentation by demographic characteristics at enrollment. RESULTS The median presenting CD4(+) cell count decreased from 371 cells/mm(3) during 1990-1994 to 276 cells/mm(3) during 2003-2006 (P<.01) overall and decreased within individual demographic groups. There was also a decrease in the median time from HIV diagnosis to presentation for care (271 days in 1990-1994 to 196 days in 2003-2006; P<.01). Multivariate analysis revealed that, in addition to CD4(+) cell count at presentation, male sex was associated with lower CD4(+) cell counts (-93 cells/mm(3)), as was black race (-71 cells/mm(3)) and older age (-20 cells/mm(3) per 10 years). CONCLUSIONS There has been a decrease in time from diagnosis of HIV infection to presentation for care, coupled with an increase in the severity of immunocompromise at time of presentation, over the past 16 years in Maryland. New strategies to provide earlier HIV testing and referral into care are urgently needed.
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Affiliation(s)
- Jeanne C Keruly
- Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
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Grinsztejn B, Veloso VG, Pilotto JH, Campos DP, Keruly JC, Moore RD. Comparison of clinical response to initial highly active antiretroviral therapy in the patients in clinical care in the United States and Brazil. J Acquir Immune Defic Syndr 2007; 45:515-20. [PMID: 17558332 DOI: 10.1097/qai.0b013e3180decb6a] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND US and Brazilian studies indicate that highly active antiretroviral therapy (HAART) has been effective in reducing morbidity and mortality from HIV/AIDS. Differences exist in the adoption and patterns of antiretroviral drug use and in the incidence of AIDS-defining illness (ADI) between the 2 countries, however, and there has not been a direct comparison of clinical response between Brazil and the United States. We sought to determine if there have been differences in the clinical response to HAART from HIV clinical practices in the United States and Brazil. METHODS We compared 2 similarly designed clinical cohorts from Baltimore, Maryland and Rio de Janeiro, Brazil. Patients who started HAART from 1997 to 2004 were compared for HIV-1 RNA suppression and CD4+ T-lymphocyte count change by 1 year of therapy and for development of an ADI up to 6 years of follow-up. A total of 1368 patients from Baltimore and 1045 patients from Rio de Janeiro were studied. RESULTS There was no difference by location in achieving an HIV-1 RNA level <400 copies/mL (46.9% in Rio de Janeiro, 50.8% in Baltimore), in the log change in HIV-1 RNA level (-1.65 log in Rio de Janeiro, - 1.63 log in Baltimore), or in the change in CD4 count (116 cells/mm3 in Rio de Janeiro, 122 cells/mm3 in Baltimore) by 12 months after starting HAART. By Kaplan-Meier analysis and Cox regression adjusted for demographic and clinical prognostic factors, there was no difference by location in development of the first ADI after starting HAART (relative hazard = 1.02; 95% confidence interval: 0.82 to 1.25 for Rio de Janeiro vs. Baltimore). The most commonly occurring ADI in Rio de Janeiro was tuberculosis (27.7% of patients), and the most commonly occurring ADI in Baltimore was esophageal candidiasis (36.8% of patients). CONCLUSIONS There were only minor differences in clinical response to the use of HAART comparing Rio de Janeiro with Baltimore, despite differences in patterns of antiretroviral drug use and ADI incidence. This analysis indicates that HAART can be similarly effective in treating HIV/AIDS in countries with different economies.
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Affiliation(s)
- Beatriz Grinsztejn
- Instituto de Pesquisa Clinica Evandro Chagas-Fiocruz, Rio de Janeiro, Brazil
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Moore RD, Keruly JC. CD4+ Cell Count 6 Years after Commencement of Highly Active Antiretroviral Therapy in Persons with Sustained Virologic Suppression. Clin Infect Dis 2007; 44:441-6. [PMID: 17205456 DOI: 10.1086/510746] [Citation(s) in RCA: 304] [Impact Index Per Article: 17.9] [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] [Received: 08/11/2006] [Accepted: 09/28/2006] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Sustained suppression of the human immunodeficiency virus (HIV) type 1 RNA load with the use of highly active antiretroviral therapy (HAART) results in immunologic improvement, but it is not clear whether the CD4(+) cell count increases to normal levels or whether it reaches a less-than-normal plateau. We characterized the increase in the CD4(+) cell count in patients in clinical practice who maintained sustained viral suppression for up to 6 years. METHODS All patients were from the Johns Hopkins HIV Clinical Cohort, a longitudinal observational study of patients receiving primary HIV care in Baltimore, Maryland, who were observed for >1 year while receiving HAART and who had sustained suppression of the HIV RNA load at <400 copies/mL. We analyzed annual change in the CD4(+) cell count for up to 6 years after the start of HAART, stratified by baseline CD4(+) cell counts of < or =200, 201-350, >350 cells/microL, and we assessed the development of clinical events (death and new acquired immunodeficiency syndrome-defining illness) by Kaplan-Meier analysis. RESULTS A total of 655 patients were observed for a median of 46 months (range, 13-72 months). The median change from baseline to most recent CD4(+) cell count was +274 cells/microL, with 92% of patients having an increase in CD4(+) cell count. By 6 years, the median CD4(+) cell count was 493 cells/microL among patients with baseline CD4(+) cell counts < or =200 cells/microL, 508 cells/microL among those with baseline CD4(+) cell counts of 201-350 cells/microL, and 829 cells/microL among those with baseline CD4(+) cell counts >350 cells/microL. In addition to baseline CD4(+) cell count, injection drug use and older age were associated with a lesser CD4(+) cell count response, and duration of therapy was associated with a greater CD4(+) cell count response. CONCLUSION Only patients with baseline CD4(+) cell counts >350 cells/microL returned to nearly normal CD4(+) cell counts after 6 years of follow-up. Significant increases were observed in all CD4(+) cell count strata during the first year, but there was a lower plateau CD4(+) cell count at lower baseline CD4(+) cell strata. These data suggest that waiting to start HAART at lower CD4(+) cell counts will result in the CD4(+) cell count not returning to normal levels.
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Affiliation(s)
- Richard D Moore
- Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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