Life expectancy after HIV diagnosis based on national HIV surveillance data from 25 states, United States

The global north: HIV epidemiology in high-income countries

PURPOSE OF REVIEW

The epidemiology of HIV epidemics provides the roadmap for prioritization of programmes and serves over time to evaluate broadly the successes and challenges in prevention. The purpose of this review was to summarize recent information about the epidemiology of HIV in high-income countries with concentrated HIV epidemics.

RECENT FINDINGS

Data from 26 countries were organized and analysed, and a systematic review of published literature relating to epidemiology in these countries was conducted. Our major findings illustrated strong patterns in epidemiology by mode of HIV acquisition: in most high-income countries, new HIV diagnoses attributable to male-female sex have been stable or decreasing, whereas new HIV diagnoses attributable to male-male sex have been stable or increasing. Late diagnoses of HIV infection are common. Prevalence of HIV in high-income countries has risen over the past 5 years as death rates have been stable or decreasing. Reports of the epidemiology of HIV among sex workers and transgendered persons are rare.

SUMMARY

The epidemiology of HIV in high-income countries in 2013 depicts both the successes and challenges of HIV prevention. The stable to decreasing death rates and stable or declining trends in heterosexual populations are likely attributable, at least in part, to the broader availability of effective treatments for HIV and relatively broad availability of antiretroviral treatment in these countries. However, late diagnoses undermine the individual and public health value of antiretroviral treatment, and epidemics of HIV among MSM remain largely uncontrolled despite broad availability and coverage of treatment.

Survival after cancer in Italian persons with AIDS, 1986-2005: a population-based estimation

BACKGROUND

Cancer survival in persons with AIDS (PWA) after introduction of antiretroviral therapies remains poorly characterized. The aim is to provide population-based estimates of cancer survival, overall and for the most important cancer types in PWA, and a comparison with persons without AIDS (non-PWA) affected by the same cancer.

METHODS

PWA with cancer at AIDS diagnosis or thereafter were individually matched with non-PWA by type of cancer, sex, age, year of diagnosis, area of living, and, for lymphomas, histological subtype. Five-year observed survival and hazard ratios (HRs) of death in PWA versus non-PWA with 95% confidence intervals (CIs) were estimated.

RESULTS

We included 2262 Italian PWA and 4602 non-PWA with cancer diagnosed during 1986-2005. Between 1986 and 1995, and 1996 and 2005, 5-year survival for all cancers in PWA improved from 12% to 41% and the corresponding HR versus non-PWA decreased from 5.1 (95% CI: 4.3 to 6.1) to 2.9 (95% CI: 2.6 to 3.3). During 1996-2005, HRs were 2.0 (95% CI: 1.4 to 2.9) for Kaposi sarcoma, 3.4 (95% CI: 2.9 to 4.1) for non-Hodgkin lymphoma, and 2.4 (95% CI: 1.4 to 4.0) for cervical cancer. HRs were 2.5 (95% CI: 2.1 to 3.1) for all non-AIDS-defining cancers, 5.9 (95% CI: 3.1 to 11.2) for Hodgkin lymphoma, and 7.3 (95% CI: 2.8 to 19.2) for nonmelanoma skin cancer. A ≤3-fold survival difference was found for cancers of the stomach, liver, anus, lung, brain, and the most aggressive lymphoma subtypes.

CONCLUSIONS

The persisting, although narrowing, gap in cancer survival between PWA and non-PWA indicates the necessity of enhancing therapeutic approaches, so that PWA can be provided the same chances of survival observed in the general population, and improving cancer prevention and screening.

Liposomal anthracycline chemotherapy and the risk of second malignancies in patients with Kaposi's sarcoma (KS)

PURPOSE

People living with HIV (PLWH) are at increased risk of cancer, both non-AIDS- and AIDS-defining malignancies (NADM and ADM). Systemic chemotherapy also predisposes to secondary cancers. The potential contribution of systemic liposomal anthracycline chemotherapy (SLAC) to the development of second cancers in PLWH is unknown.

METHODS

Since 1998, we have treated 495 PLWH and Kaposi's sarcoma (KS) with a stage-stratified approach including 163 who received SLAC as first-line treatment for KS. Subsequent ADM and NADM diagnosed in this population were recorded.

RESULTS

More patients who received SLAC had T1 stage disease (p < 0.0001) and lower CD4 cell counts (p < 0.0001) in line with the stage-stratified treatment, but there were no significant differences in age (p = 0.29), gender (p = 0.18), prior AIDS-defining illness (p = 0.45), plasma HIV viral load (p = 0.15), or HHV8 viral load (p = 0.39) between the two groups. During a median follow-up of 4.6 years (maximum 15 years) from KS diagnosis, 28 patients developed a second cancer (5 ADM and 23 NADM). The 5-year cumulative risk of second cancer is 5.8 % (95 % CI 3.0-8.6 %), and there is no significant difference in the rate between those treated with SLAC and those not (log rank p = 0.19). Most patients (n = 131) were treated with daunoxome (liposomal daunorubicin) chemotherapy, and there was no significant correlation between risk of second cancer and cumulative dose of daunoxome (p = 0.23).

CONCLUSION

Although the risk of second cancer after a diagnosis of KS in PLWH is high, systemic liposomal anthracycline chemotherapy does not appear to increase the risk.

Delayed-type hypersensitivity and hepatitis B vaccine responses, in vivo markers of cellular and humoral immune function, and the risk of AIDS or death

BACKGROUND

Delayed-type hypersensitivity (DTH) test responsiveness is associated with HIV disease progression; however it is unknown whether other immune markers, such as hepatitis B virus (HBV) vaccine seroresponse, also predict HIV outcomes.

METHODS

Eligible participants received HBV vaccine after HIV diagnosis, had non-anergic DTH testing at the time of last HBV vaccination, and available post-vaccine HBV antibody responses. The risk of progression to AIDS or death from the time of last HBV vaccination was evaluated.

RESULTS

Of 369 eligible participants with non-anergic DTH responses, 148 (40%) were HBV vaccine responders. In a multivariate model adjusted for age, CD4 count, viral load, and number of vaccinations, HBV vaccine non-responders had an increased risk of progression to AIDS or death (HR 1.81; 95% CI, 1.03-3.19).

CONCLUSIONS

HBV vaccine seroresponses were independent of DTH responses which suggest that non-response to HBV vaccine is not solely due to cell-mediated immune dysfunction in HIV-infected persons.

Glycoproteomic analysis identifies human glycoproteins secreted from HIV latently infected T cells and reveals their presence in HIV+ plasma

Glycoproteins secreted into plasma from T cells infected with human immunodeficiency virus (HIV) latent infection may provide insight into understanding the host response to HIV infection in vivo. Glycoproteomics, which evaluates the level of the glycoproteome, remains a novel approach to study this host response to HIV. In order to identify human glycoproteins secreted from T cells with latent HIV infection, the medium from cultured HIV replication-competent T cells was compared with the medium from cultured parental A3.01 cells via solid phase extraction of glycopeptides (SPEG) and high-performance liquid chromatography-tandem mass spectrometry (HPLC-MS/MS). Using these methods, 59 human glycoproteins were identified as having significantly different abundance levels between the media from these two cell lines. The relevance of these 59 proteins to HIV infection in vivo was assessed in plasma from HIV+ and HIV- subjects. Comparison between T cell and plasma revealed that six glycoproteins (galectin-3-binding protein, L-selectin, neogenin, adenosine deaminase CECR1, ICOS ligand and phospholipid transfer protein) were significantly elevated in the HIV+ T cells and plasma studies. These findings suggest that the response of T cells harboring latent HIV infection contributed, in part, to the glycoprotein changes in HIV+ plasma. These proteins, once validated, could provide insight into host-HIV interaction.

Spatial epidemiology of recently acquired HIV infections across rural and urban areas of North Carolina

Transmission of HIV continues in the United States (US), despite prevention efforts aimed at education and treatment. Concurrently, drug resistance in HIV, particularly in patients being infected with HIV for the first time, poses a threat to the continued success of treatment for HIV positive individuals. In North Carolina, nearly one in five individuals with acute HIV infection (AHI) is infected with a drug-resistant strain, a phenomenon known as transmitted drug resistance (TDR). Few studies of AHI or TDR take into account both the spatial aspects of residence at time of infection and the genetic characteristics of the viruses, and questions remain about how viruses are transmitted across space and the rural-urban divide. Using AHI strains from North Carolina, we examined whether differences exist in the spatial patterns of AHI versus AHI with TDR, as well as whether the genetic characteristics of these HIV infections vary by rural-urban status and across Health Service Areas. The highest amounts of TDR were detected in persons under age 30, African Americans, and men who have sex with men (MSM) - similar to the populations where the highest numbers of AHI without TDR are observed. Nearly a quarter of patients reside in rural areas, and there are no significant differences between rural and urban residence among individuals infected with drug resistant or drug susceptible viruses. We observe similar levels of genetic distance between HIV found in rural and urban areas, indicating that viruses are shared across the rural-urban divide. Genetic differences are observed, however, across Health Service Areas, suggesting that local areas are sites of genetic differentiation in viruses being transmitted to newly infected individuals. These results indicate that future efforts to prevent HIV transmission need to be spatially targeted, focusing on local-level transmission in risky populations, in addition to statewide anti- HIV efforts.

A multicenter study of initiation of antiretroviral therapy and transmitted drug resistance in antiretroviral-naive adolescents and young adults with HIV in New York City

BACKGROUND

In December 2009, the Department of Health and Human Services guidelines for initiation of antiretroviral therapy (ART) changed to include patients with CD4 counts between 350 and 500 cells/µL. The aims of this study were to assess uptake of this recommendation in ART-naive youth with human immunodeficiency virus (HIV) and to describe the epidemiology of transmitted genotypic drug resistance mutations (DRMs) in this population.

METHODS

A multicenter, retrospective cohort study of ART initiation in ART-naive youth was performed. Eligible subjects were 13-25 years of age, were diagnosed with HIV within 1 year of presentation to care at the study sites, and presented to care from January 2007 to June 2011.

RESULTS

Of 685 potential subjects identified, 331 (49%) fulfilled inclusion criteria. Mean CD4 count at presentation to care was 452 cells/µL. Overall, 191 (58%) subjects started ART. The mean CD4 count at ART initiation was 261 cells/µL before and 363 cells/µL after the 2009 guideline change (P < .0001). Of 212 (64%) subjects with resistance testing available prior to ART initiation, 38 (18%) subjects had a major DRM and an increased proportion of resistance was seen in later study years.

CONCLUSIONS

Our study demonstrated an uptake in recently changed guideline recommendations to treat HIV-infected individuals at higher CD4 counts and reinforces the importance of performing resistance testing at entry into care, as 18% of our population had major DRMs prior to initiation of ART.

Serious Non-AIDS events: Immunopathogenesis and interventional strategies

Despite the major advances in the management of HIV infection, HIV-infected patients still have greater morbidity and mortality than the general population. Serious non-AIDS events (SNAEs), including non-AIDS malignancies, cardiovascular events, renal and hepatic disease, bone disorders and neurocognitive impairment, have become the major causes of morbidity and mortality in the antiretroviral therapy (ART) era. SNAEs occur at the rate of 1 to 2 per 100 person-years of follow-up. The pathogenesis of SNAEs is multifactorial and includes the direct effect of HIV and associated immunodeficiency, underlying co-infections and co-morbidities, immune activation with associated inflammation and coagulopathy as well as ART toxicities. A number of novel strategies such as ART intensification, treatment of co-infection, the use of anti-inflammatory drugs and agents that reduce microbial translocation are currently being examined for their potential effects in reducing immune activation and SNAEs. However, currently, initiation of ART before advanced immunodeficiency, smoking cessation, optimisation of cardiovascular risk factors and treatment of HCV infection are most strongly linked with reduced risk of SNAEs or mortality. Clinicians should therefore focus their attention on addressing these issues prior to the availability of further data.

Community-Based Pharmacists’ Needs for HIV-Related Training and Experience

Objective:

To examine pharmacists’ self-reported competence in providing care to persons living with HIV (PLWH) and their HIV-related training and experience needs.

Methods:

We interviewed 28 community-based pharmacists providing care to PLWH in 4 Midwestern cities. Results: Less than half (46%) of the pharmacists considered themselves competent to provide PLWH care, and less than a third (29%) worked with PLWH during their pharmacy residency. Specialty pharmacists need training on opportunistic infections and HIV-related comorbidities, nonspecialty pharmacists need general training in HIV treatment and patient communications skills, and all pharmacists require a mechanism to keep updated in the latest HIV treatment recommendations.

Conclusion:

In the current era of patient-centered care, a pharmacist that is well rounded—not just in dispensing antiretroviral medications but highly knowledgeable in different aspects of ART and HIV-specific patient care—can make a valuable contribution to the health care team. Pharmacy school curricula and continuing professional education need to be aligned to meet the knowledge and competency needs of community pharmacists who are strategically positioned to provide care to PLWH.

HIV-1 infection induces strong production of IP-10 through TLR7/9-dependent pathways

OBJECTIVE

To study the cytokine/chemokine profiles in response to HIV-1 viremia, and elucidate the pathways leading to HIV-1-induced inflammation.

DESIGN/METHODS

Plasma levels of 19 cytokines in individuals with early HIV-1 infection and individuals undergoing treatment interruptions were evaluated via multiplex assay. To investigate the cellular sources of relevant cytokines, sorted cells from HIV-1 infected individuals were assessed for mRNA expression. Relevant signaling pathways were assessed by comparing cytokine production patterns of peripheral blood mononuclear cells stimulated with intact HIV-1 or specific Toll-like receptor (TLR) stimulants with and without a TLR7/9 antagonist.

RESULTS

IP-10 plasma concentration was most significantly associated with HIV-1 viral load and was the most significant contributor in a multivariate model. IP-10 mRNA was highly expressed in monocytes and mDCs and these cells were the dominant producers after in-vitro stimulation with TLR7/8 ligands (CL097 and ssRNAGag1166), AT-2 HIV-1, and HIV-1NL43 virus. Partial least square discriminant analysis of culture supernatants revealed distinct cytokine/chemokine secretion profiles associated with intact viruses compared with TLR7/8 ligands alone, with IP-10 production linked to the former. A TLR7/9 antagonist blocked IP-10 production following whole virus stimulation, suggesting the involvement of TLR7/9 in the recognition of HIV-1 by these cells.

CONCLUSION

Monocytes and mDCs produce significant amounts of IP-10 in response to HIV-1 viremia and after in-vitro stimulation with HIV-1. Stimulation with HIV-1-derived TLR7/8-ligands versus HIV-1 resulted in distinct cytokine/chemokine profiles, indicating additional pathways other than TLR7/8 that lead to the activation of innate immune cells by HIV-1.

Gender differences in baseline health, needs at release, and predictors of care engagement among HIV-positive clients leaving jail

Women represent a significant and growing segment of jail detainees and persons living with HIV. This paper examines gender differences in health status, care and social service needs, and care engagement among jail releasees with HIV. Data are from 1,270 participants in the HRSA-funded Enhancing Linkages to HIV Primary Care and Social Services multisite demonstration project (EnhanceLink). Compared to men, more women reported homelessness, reduced adherence to prescribed ART, worse health, more severe substance use disorders, and more chronic health conditions. Men and women generally reported different needs post-release. As the number of expressed needs increased, women were more likely to drop out of care. Our findings suggest that effective and gender-specific strategies are required to identify needs, link services between jails and communities, and sustain retention of women with HIV in programs after release from criminal justice settings.

Potential health impacts of heavy metals on HIV-infected population in USA

PURPOSE

Noninfectious comorbidities such as cardiovascular diseases have become increasingly prevalent and occur earlier in life in persons with HIV infection. Despite the emerging body of literature linking environmental exposures to chronic disease outcomes in the general population, the impacts of environmental exposures have received little attention in HIV-infected population. The aim of this study is to investigate whether individuals living with HIV have elevated prevalence of heavy metals compared to non-HIV infected individuals in United States.

METHODS

We used the National Health and Nutrition Examination Survey (NHANES) 2003-2010 to compare exposures to heavy metals including cadmium, lead, and total mercury in HIV infected and non-HIV infected subjects.

RESULTS

In this cross-sectional study, we found that HIV-infected individuals had higher concentrations of all heavy metals than the non-HIV infected group. In a multivariate linear regression model, HIV status was significantly associated with increased blood cadmium (p=0.03) after adjusting for age, sex, race, education, poverty income ratio, and smoking. However, HIV status was not statistically associated with lead or mercury levels after adjusting for the same covariates.

CONCLUSIONS

Our findings suggest that HIV-infected patients might be significantly more exposed to cadmium compared to non-HIV infected individuals which could contribute to higher prevalence of chronic diseases among HIV-infected subjects. Further research is warranted to identify sources of exposure and to understand more about specific health outcomes.

Initiation of antiretroviral therapy in youth with HIV: a U.S.-based provider survey

In 2009, the Department of Health and Human Services (DHHS) recommended initiating antiretroviral therapy (ART) for youth with HIV at higher CD4 counts (≤500 cells/mm³) than previously recommended (≤350 cells/mm³). Barriers experienced by providers regarding ART initiation in this population have not been assessed. From 12/2011-01/2012, we asked providers from the American Academy of HIV Medicine (AAHIVM) [corrected] listserv who prescribed ART to youth (ages 13-25 years) with behaviorally-acquired HIV to complete a web-based survey. We presented a clinical vignette to explore potential barriers for initiating ART. Overall, 274/290 (94%) respondents completed the survey. Most felt confident that evidence supported initiating ART at higher CD4 counts (94%), and that benefits outweighed the risks of long-term toxicity (98%) or developing resistance (88%). Most (96%) initiated ART in the patient vignette (age 19 years, CD4 count ~400). Patient characteristics (e.g., unstable housing or drug use) were perceived as large barriers to ART initiation. Low response rate (13%) was a limitation. Respondents were knowledgeable about relevant DHHS guidelines, believed sufficient evidence supported ART initiation at higher CD4 counts, and would provide treatment to those with CD4 counts ≤500cells/mm³. Understanding and overcoming barriers to initiation of ART perceived by providers is important to ensure implementation of ART treatment guidelines.

Cost-effectiveness of pneumococcal conjugate vaccination in immunocompromised adults

OBJECTIVE

Pneumococcal disease is a significant problem in immunocompromised persons, particularly in HIV-infected individuals. The CDC recently updated pneumococcal vaccination recommendations for immunocompromised adults, adding the 13-valent pneumococcal conjugate vaccine (PCV13) to the previously recommended 23-valent pneumococcal polysaccharide vaccine (PPSV23). This analysis estimates the cost-effectiveness of pneumococcal vaccination strategies in HIV-infected individuals and in the broader immunocompromised adult group.

DESIGN

Markov model-based cost-effectiveness analysis.

METHODS

The model considered immunocompromised persons aged 19-64 years and accounted for childhood PCV13 herd immunity; in a separate analysis, an HIV-infected subgroup was considered. PCV13 effectiveness was estimated by an expert panel; PPSV23 protection was modeled relative to PCV13 effectiveness. We assumed that both vaccines prevented invasive pneumococcal disease, but only PCV13 prevented nonbacteremic pneumonia.

RESULTS

In all immunocompromised individuals, a single PCV13 cost $70,937 per quality adjusted life year (QALY) gained compared to no vaccination; current recommendations cost $136,724/QALY. In HIV patients, with a longer life expectancy (22.5 years), current recommendations cost $89,391/QALY compared to a single PCV13. Results were sensitive to variation of life expectancy and vaccine effectiveness. The prior recommendation was not favored in any scenario.

CONCLUSIONS

One dose of PCV13 is more cost-effective for immunocompromised individuals than previous vaccination recommendations and may be more economically reasonable than current recommendations, depending on life expectancy and vaccine effectiveness in the immunocompromised.

Pharmacokinetics of Single-Dose Dolutegravir in HIV-Seronegative Subjects With Moderate Hepatic Impairment Compared to Healthy Matched Controls

This study evaluated dolutegravir pharmacokinetics (PK) in subjects with moderate hepatic impairment compared to matched, healthy controls. In this open-label, parallel-group study, eight adult subjects with moderate hepatic impairment (Child-Pugh Score 7–9) and eight healthy subjects matched for gender, age, and body mass index received a single dolutegravir 50-mg dose. Following dosing, 72-hour PK sampling was performed to determine total and unbound dolutegravir concentrations. PK parameters were calculated using non-compartmental analysis. Geometric least squares mean ratios (GMR) and 90% confidence intervals (CIs) in subjects with hepatic impairment versus healthy subjects were generated by analysis of variance. Results showed that PK parameters of total plasma dolutegravir were similar between subject groups. The unbound fraction was higher in subjects with moderate hepatic impairment than in healthy subjects with GMR (90% CI) of 2.20 (1.62, 2.99) for unbound fraction at 3 hours post-dose and 1.76 (1.23, 2.51) for unbound fraction at 24 hours post-dose; this correlated with lower serum albumin concentrations and was not considered clinically significant. Dolutegravir was well tolerated in both groups; all adverse events were reported as minor. Although free fraction was increased, no dose adjustment is required for patients treated with dolutegravir who have mild to moderate hepatic impairment.

HIV protease inhibitors in pregnancy : pharmacology and clinical use

The impact of antiretroviral therapy (ART) on the natural history of HIV-1 infection has resulted in dramatic reductions in disease-associated morbidity and mortality. Additionally, the epidemiology of HIV-1 infection worldwide is changing, as women now represent a substantial proportion of infected adults. As more highly effective and tolerable antiretroviral regimens become available, and as the prevention of mother-to-child transmission becomes an attainable goal in the management of HIV-infected individuals, more and more HIV-positive women are choosing to become pregnant and have children. Consequently, it is important to consider the efficacy and safety of antiretroviral agents in pregnancy. Protease inhibitors are a common class of medication used in the treatment of HIV-1 infection and are increasingly being used in pregnancy. However, several studies have raised concerns regarding pharmacokinetic alterations in pregnancy, particularly in the third trimester, which results in suboptimal drug concentrations and a theoretically higher risk of virologic failure and perinatal transmission. Drug level reductions have been observed with each individual protease inhibitor and dose adjustments in pregnancy are suggested for certain agents. Furthermore, studies have also raised concerns regarding the safety of protease inhibitors in pregnancy, particularly as they may increase the risk of pre-term birth and metabolic disturbances. Overall, protease inhibitors are safe and effective for the treatment of HIV-infected pregnant women. Specifically, ritonavir-boosted lopinavir- and atazanavir-based regimens are preferred in pregnancy, while ritonavir-boosted darunavir- and saquinavir-based therapies are reasonable alternatives. This paper reviews the use of protease inhibitors in pregnancy, focusing on pharmacokinetic and safety considerations, and outlines the recommendations for use of this class of medication in the HIV-1-infected pregnant woman.

Lipodystrophy and inflammation predict later grip strength in HIV-infected men: the MACS Body Composition substudy

Body fat changes in HIV-infected persons are associated with increased systemic inflammation and increased mortality. It is unknown whether lipodystrophy is also associated with declines in physical function. Between 2001 and 2003, 33 HIV-infected men with evidence of lipodystrophy (LIPO⁺), 23 HIV-infected men without lipodystrophy (LIPO⁻), and 33 seronegative men were recruited from the Multicenter AIDS Cohort Study (MACS) for the Body Composition substudy. Visceral adipose tissue (VAT) was assessed by quantitative computed tomography. Lean body mass (LBM) and extremity fat were measured by dual-energy x-ray absorptiometry. Insulin resistance was estimated by Homeostatic Model Assessment (HOMA). Serum interleukin (IL)-6, soluble tumor necrosis factor (TNF)-α receptors I and II (sTNFRI and sTNFRII), and highly sensitive C-reactive protein (hs-CRP) concentrations were quantified from archived serum samples. These measurements were correlated with grip strength measured in 2007 using linear regression. At the substudy visit, the LIPO⁺ group had higher HOMA, sTNFRI, sTNFRII, and IL-6 levels than the LIPO⁻ group. In 2007, the LIPO⁺ group had lower median grip strength than the LIPO⁻ group (34.4 vs. 42.7 kg, p=0.002). Multivariable analysis of HIV⁺ men showed older age, lower LBM, higher sTNFRII concentrations, and LIPO⁺ status [adjusted mean difference -4.9 kg (p=0.045)] at the substudy visit were independently associated with lower subsequent grip strength. Inflammation, lower LBM, and lipodystrophy in HIV-infected men were associated with lower subsequent grip strength. These findings suggest that inflammation may contribute to declines in functional performance, independent of age.

Survival rate of AIDS disease and mortality in HIV-infected patients in Hamadan, Iran: a registry-based retrospective cohort study (1997-2011)

There remains a need to better understand the prognostic factors affecting the long-term survival in patients with human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS), particularly in developing countries. We extracted data from 585 patients' medical records available at the triangular clinics for behavioural diseases. The outcomes of interest were the survival rates of progression to AIDS and death in HIV-positive subjects. The effect of several prognostic factors on survival time was investigated. One-year, five-year and 10-year survival rates from time of HIV diagnosis to AIDS were 89%, 69% and 30%, respectively. One-year and five-year survival rates from AIDS to death were 76% and 46%, respectively. One-year, five-year and 10-year survival rate from HIV diagnosis to death were 87%, 67% and 40%, respectively. Hazard ratio of progression to AIDS in HIV-positive subjects who were co-infected with tuberculosis was 4.50 (p < 0.001). Hazard ratio of death from AIDS-related causes was 4.77 in patients who did not receive highly active antiretroviral therapy compared to those who did (p < 0.001). Co-infection with tuberculosis was one of the most important prognostic factors of progression to AIDS and antiretroviral treatment was found to be an effective measure in suppressing HIV viral replication and improving the survival of patients living with HIV.

Shifting the paradigm: using HIV surveillance data as a foundation for improving HIV care and preventing HIV infection

CONTEXT

Reducing HIV incidence in the United States and improving health outcomes for people living with HIV hinge on improving access to highly effective treatment and overcoming barriers to continuous treatment. Using laboratory tests routinely reported for HIV surveillance to monitor individuals' receipt of HIV care and contacting them to facilitate optimal care could help achieve these objectives. Historically, surveillance-based public health intervention with individuals for HIV control has been controversial because of concerns that risks to privacy and autonomy could outweigh benefits. But with the availability of lifesaving, transmission-interrupting treatment for HIV infection, some health departments have begun surveillance-based outreach to facilitate HIV medical care.

METHODS

Guided by ethics frameworks, we explored the ethical arguments for changing the uses of HIV surveillance data. To identify ethical, procedural, and strategic considerations, we reviewed the activities of health departments that are using HIV surveillance data to contact persons identified as needing assistance with initiating or returning to care.

FINDINGS

Although privacy concerns surrounding the uses of HIV surveillance data still exist, there are ethical concerns associated with not using HIV surveillance to maximize the benefits from HIV medical care and treatment. Early efforts to use surveillance data to facilitate optimal HIV medical care illustrate how the ethical burdens may vary depending on the local context and the specifics of implementation. Health departments laid the foundation for these activities by engaging stakeholders to gain their trust in sharing sensitive information; establishing or strengthening legal, policy and governance infrastructure; and developing communication and follow-up protocols that protect privacy.

CONCLUSIONS

We describe a shift toward using HIV surveillance to facilitate optimal HIV care. Health departments should review the considerations outlined before implementing new uses of HIV surveillance data, and they should commit to an ongoing review of activities with the objective of balancing beneficence, respect for persons, and justice.

Trends in the population prevalence of people who inject drugs in US metropolitan areas 1992-2007

BACKGROUND

People who inject drugs (PWID) have increased risk of morbidity and mortality. We update and present estimates and trends of the prevalence of current PWID and PWID subpopulations in 96 US metropolitan statistical areas (MSAs) for 1992-2007. Current estimates of PWID and PWID subpopulations will help target services and help to understand long-term health trends among PWID populations.

METHODOLOGY

We calculated the number of PWID in the US annually from 1992-2007 and apportioned estimates to MSAs using multiplier methods. We used four types of data indicating drug injection to allocate national annual totals to MSAs, creating four distinct series of component estimates of PWID in each MSA and year. The four component estimates are averaged to create the best estimate of PWID for each MSA and year. We estimated PWID prevalence rates for three subpopulations defined by gender, age, and race/ethnicity. We evaluated trends using multi-level polynomial models.

RESULTS

PWID per 10,000 persons aged 15-64 years varied across MSAs from 31 to 345 in 1992 (median 104.4) to 34 to 324 in 2007 (median 91.5). Trend analysis indicates that this rate declined during the early period and then was relatively stable in 2002-2007. Overall prevalence rates for non-Hispanic black PWID increased in 2005 as compared to other racial/ethnic groups. Hispanic prevalence, in contrast, declined across time. Importantly, results show a worrisome trend in young PWID prevalence since HAART was initiated--the mean prevalence was 90 to 100 per 10,000 youth in 1992-1996, but increased to >120 PWID per 10,000 youth in 2006-2007.

CONCLUSIONS

Overall, PWID rates remained constant since 2002, but increased for two subpopulations: non-Hispanic black PWID and young PWID. Estimates of PWID are important for planning and evaluating public health programs to reduce harm among PWID and for understanding related trends in social and health outcomes.

Life expectancy living with HIV: recent estimates and future implications

PURPOSE OF REVIEW

The life expectancy of people living with HIV has dramatically increased since effective antiretroviral therapy has been available, and still continues to improve. Here, we review the latest literature on estimates of life expectancy and consider the implications for future research.

RECENT FINDINGS

With timely diagnosis, access to a variety of current drugs and good lifelong adherence, people with recently acquired infections can expect to have a life expectancy which is nearly the same as that of HIV-negative individuals. Modelling studies suggest that life expectancy could improve further if there were increased uptake of HIV testing, better antiretroviral regimens and treatment strategies, and the adoption of healthier lifestyles by those living with HIV. In particular, earlier diagnosis is one of the most important factors associated with better life expectancy. A consequence of improved survival is the increasing number of people with HIV who are aged over 50 years old, and further research into the impact of ageing on HIV-positive people will therefore become crucial. The development of age-specific HIV treatment and management guidelines is now called for.

SUMMARY

Analyses on cohort studies and mathematical modelling studies have been used to estimate life expectancy of those with HIV, providing useful insights of importance to individuals and healthcare planning.

Metropolitan social environments and pre-HAART/HAART era changes in mortality rates (per 10,000 adult residents) among injection drug users living with AIDS

Background

Among the largest US metropolitan areas, trends in mortality rates for injection drug users (IDUs) with AIDS vary substantially. Ecosocial, risk environment and dialectical theories suggest many metropolitan areas characteristics that might drive this variation. We assess metropolitan area characteristics associated with decline in mortality rates among IDUs living with AIDS (per 10,000 adult MSA residents) after highly active antiretroviral therapy (HAART) was developed.

Methods

This is an ecological cohort study of 86 large US metropolitan areas from 1993–2006. The proportional rate of decline in mortality among IDUs diagnosed with AIDS (as a proportion of adult residents) from 1993–1995 to 2004–2006 was the outcome of interest. This rate of decline was modeled as a function of MSA-level variables suggested by ecosocial, risk environment and dialectical theories. In multiple regression analyses, we used 1993–1995 mortality rates to (partially) control for pre-HAART epidemic history and study how other independent variables affected the outcomes.

Results

In multivariable models, pre-HAART to HAART era increases in ‘hard drug’ arrest rates and higher pre-HAART income inequality were associated with lower relative declines in mortality rates. Pre-HAART per capita health expenditure and drug abuse treatment rates, and pre- to HAART-era increases in HIV counseling and testing rates, were weakly associated with greater decline in AIDS mortality.

Conclusions

Mortality among IDUs living with AIDS might be decreased by reducing metropolitan income inequality, increasing public health expenditures, and perhaps increasing drug abuse treatment and HIV testing services. Given prior evidence that drug-related arrest rates are associated with higher HIV prevalence rates among IDUs and do not seem to decrease IDU population prevalence, changes in laws and policing practices to reduce such arrests while still protecting public order should be considered.

Community poverty and trends in racial/ethnic survival disparities among people diagnosed with AIDS in Florida, 1993-2004

OBJECTIVES

We described the racial/ethnic disparities in survival among people diagnosed with AIDS in Florida from 1993 to 2004, as the availability of highly active antiretroviral therapy (HAART) became widespread. We determined whether these disparities decreased after controlling for measures of community-level socioeconomic status.

METHODS

We compared survival from all causes between non-Hispanic Blacks and non-Hispanic Whites vis-a-vis survival curves and Cox proportional hazards models controlling for demographic, clinical, and area-level poverty factors.

RESULTS

Racial/ethnic disparities in survival peaked for those diagnosed during the early implementation of HAART (1996-1998) with a Black-to-White hazard ratio (HR) of 1.72 (95% confidence interval [CI] = 1.62, 1.83) for males and 1.40 (95% CI = 1.24, 1.59) for females. These HRs declined significantly to 1.48 (95% CI = 1.35, 1.64) for males and nonsignificantly to 1.25 (95% CI = 1.05, 1.48) for females in the 2002 to 2004 diagnosis cohort. Disparities decreased significantly for males but not females when controlling for baseline demographic factors and CD4 count and percentage, and became nonsignificant in the 2002 to 2004 cohort after controlling for area poverty.

CONCLUSIONS

Area poverty appears to play a role in racial/ethnic disparities even after controlling for demographic factors and CD4 count and percentage.

Comparison of functional status instruments in HIV-infected adults on effective antiretroviral therapy

BACKGROUND

The best method for assessment of functional status in human immunodeficiency virus type 1 (HIV-1) infected persons is unknown.

OBJECTIVE

We hypothesized that 3 instruments to assess frailty or disability in elderly populations would perform similarly in HIV-1-infected persons.

METHODS

HIV-infected subjects 45 to 65 years old with plasma HIV-1 RNA <48 copies/mL were classified prospectively as low, moderate, or high function by Fried's frailty phenotype (FFP), the Short Physical Performance Battery (SPPB), and 400-m walk test. Functional instrument agreement was evaluated by weighted kappa statistic, and relationships with demographic or clinical factors were evaluated by odds ratios (OR).

RESULTS

There were 359 participants (85% male, mean age 52 years, mean CD4+ lymphocyte count 551 cells/µL) who were evaluated. Three percent to 8% were low, 31% to 51% were moderate, and 42% to 62% were high function. FFP, SPPB, and 400-m walk test had moderate agreement for functional classification (61%-64%; κ = 0.34-0.41). Across instruments, lower reported physical activity (OR ≯ 5.5; P ≤ .005), no current employment (OR ≯ 4.2; P < .02), arthritis (OR ≯ 6.5; P < .02), neurologic disease (OR ≯ 2.6; P < .05), debilitating pain (OR ≯ 5.4; P < .008), psychiatric disease (OR ≯3.1; P < .03), more comorbidities (OR ≯ 3.6; P ≤ .005), and more non-antiretroviral therapy medications (OR ≯ 3.5; P ≤ .01) were associated with lower function. Current CD4 <200 cells/µL was more likely among low-function (11%) than high-function (2%) persons on FFP (P = .04); other HIV-related characteristics were not significantly different (P > .05) between functional categories on any instrument.

CONCLUSIONS

Moderate functional impairment is common among middle-aged HIV-infected persons, with similar frequencies of impairment detected by 3 instruments. Reduction in comorbid disease, increased physical activity, and improved pain symptom management could reduce functional impairment among persons aging with HIV-infection.

Life expectancies of South African adults starting antiretroviral treatment: collaborative analysis of cohort studies

BACKGROUND

Few estimates exist of the life expectancy of HIV-positive adults receiving antiretroviral treatment (ART) in low- and middle-income countries. We aimed to estimate the life expectancy of patients starting ART in South Africa and compare it with that of HIV-negative adults.

METHODS AND FINDINGS

Data were collected from six South African ART cohorts. Analysis was restricted to 37,740 HIV-positive adults starting ART for the first time. Estimates of mortality were obtained by linking patient records to the national population register. Relative survival models were used to estimate the excess mortality attributable to HIV by age, for different baseline CD4 categories and different durations. Non-HIV mortality was estimated using a South African demographic model. The average life expectancy of men starting ART varied between 27.6 y (95% CI: 25.2-30.2) at age 20 y and 10.1 y (95% CI: 9.3-10.8) at age 60 y, while estimates for women at the same ages were substantially higher, at 36.8 y (95% CI: 34.0-39.7) and 14.4 y (95% CI: 13.3-15.3), respectively. The life expectancy of a 20-y-old woman was 43.1 y (95% CI: 40.1-46.0) if her baseline CD4 count was ≥ 200 cells/µl, compared to 29.5 y (95% CI: 26.2-33.0) if her baseline CD4 count was <50 cells/µl. Life expectancies of patients with baseline CD4 counts ≥ 200 cells/µl were between 70% and 86% of those in HIV-negative adults of the same age and sex, and life expectancies were increased by 15%-20% in patients who had survived 2 y after starting ART. However, the analysis was limited by a lack of mortality data at longer durations.

CONCLUSIONS

South African HIV-positive adults can have a near-normal life expectancy, provided that they start ART before their CD4 count drops below 200 cells/µl. These findings demonstrate that the near-normal life expectancies of HIV-positive individuals receiving ART in high-income countries can apply to low- and middle-income countries as well. Please see later in the article for the Editors' Summary.

Heterogeneity in outcomes of treated HIV-positive patients in Europe and North America: relation with patient and cohort characteristics

BACKGROUND

HIV cohort collaborations, which pool data from diverse patient cohorts, have provided key insights into outcomes of antiretroviral therapy (ART). However, the extent of, and reasons for, between-cohort heterogeneity in rates of AIDS and mortality are unclear.

METHODS

We obtained data on adult HIV-positive patients who started ART from 1998 without a previous AIDS diagnosis from 17 cohorts in North America and Europe. Patients were followed up from 1 month to 2 years after starting ART. We examined between-cohort heterogeneity in crude and adjusted (age, sex, HIV transmission risk, year, CD4 count and HIV-1 RNA at start of ART) rates of AIDS and mortality using random-effects meta-analysis and meta-regression.

RESULTS

During 61 520 person-years, 754/38 706 (1.9%) patients died and 1890 (4.9%) progressed to AIDS. Between-cohort variance in mortality rates was reduced from 0.84 to 0.24 (0.73 to 0.28 for AIDS rates) after adjustment for patient characteristics. Adjusted mortality rates were inversely associated with cohorts' estimated completeness of death ascertainment [excellent: 96-100%, good: 90-95%, average: 75-89%; mortality rate ratio 0.66 (95% confidence interval 0.46-0.94) per category]. Mortality rate ratios comparing Europe with North America were 0.42 (0.31-0.57) before and 0.47 (0.30-0.73) after adjusting for completeness of ascertainment.

CONCLUSIONS

Heterogeneity between settings in outcomes of HIV treatment has implications for collaborative analyses, policy and clinical care. Estimated mortality rates may require adjustment for completeness of ascertainment. Higher mortality rate in North American, compared with European, cohorts was not fully explained by completeness of ascertainment and may be because of the inclusion of more socially marginalized patients with higher mortality risk.

Long-term survival in HIV positive patients with up to 15 Years of antiretroviral therapy

BACKGROUND

Life expectancy has increased for newly diagnosed HIV patients since the inception of combination antiretroviral treatment (cART), but there remains a need to better understand the characteristics of long-term survival in HIV-positive patients. We examined long-term survival in HIV-positive patients receiving cART in the Australian HIV Observational Database (AHOD), to describe changes in mortality compared to the general population and to develop longer-term survival models.

METHODS

Data were examined from 2,675 HIV-positive participants in AHOD who started cART. Standardised mortality ratios (SMR) were calculated by age, sex and calendar year across prognostic characteristics using Australian Bureau of Statistics national data as reference. SMRs were examined by years of duration of cART by CD4 and similarly by viral load. Survival was analysed using Cox-proportional hazards and parametric survival models.

RESULTS

The overall SMR for all-cause mortality was 3.5 (95% CI: 3.0-4.0). SMRs by CD4 count were 8.6 (95% CI: 7.2-10.2) for CD4<350 cells/µl; 2.1 (95% CI: 1.5-2.9) for CD4 = 350-499 cells/µl; and 1.5 (95% CI: 1.1-2.0) for CD4≥500 cells/µl. SMRs for patients with CD4 counts <350 cells/µL were much higher than for patients with higher CD4 counts across all durations of cART. SMRs for patients with viral loads greater than 400 copies/ml were much higher across all durations of cART. Multivariate models demonstrated improved survival associated with increased recent CD4, reduced recent viral load, younger patients, absence of HBVsAg-positive ever, year of HIV diagnosis and incidence of ADI. Parametric models showed a fairly constant mortality risk by year of cART up to 15 years of treatment.

CONCLUSION

Observed mortality remained fairly constant by duration of cART and was modelled accurately by accepted prognostic factors. These rates did not vary much by duration of treatment. Changes in mortality with age were similar to those in the Australian general population.

Vaccination of risk groups in England using the 13 valent pneumococcal conjugate vaccine: economic analysis

OBJECTIVE

To estimate the cost effectiveness of vaccinating people with high risk conditions against invasive pneumococcal disease using the 13 valent pneumococcal conjugate vaccine.

DESIGN

Economic evaluation using a cohort model from the perspective of healthcare providers.

SETTING

England.

PARTICIPANTS

People aged 2 years and older at increased risk of invasive pneumococcal disease due to chronic kidney disease; splenic dysfunction; HIV infection; a compromised immune system; chronic heart, liver, or respiratory disease; or diabetes.

MAIN OUTCOME MEASURES

Costs, gains in life years and quality adjusted life years (QALYs), and incremental cost effectiveness ratios.

RESULTS

Increasing indirect protection resulting from the vaccination programme of infants using the 13 valent pneumococcal conjugate vaccine means that the burden of disease preventable by targeting high risk groups will diminish in time. Under base case assumptions--that is, no overall impact on non bacteraemic pneumonia in high risk groups and assuming the high risk vaccination programme would be launched two to three years after the infant programme--the incremental cost effectiveness ratio was estimated to be more than £30,000 (€37,216; $48,210) per QALY gained for most risk groups. If, however, the vaccine does not offer protection against non-bacteraemic pneumococcal pneumonia or the vaccine was introduced concomitantly with the infant 13 valent pneumococcal conjugate vaccination programme then vaccinating high risk people would (more) likely be cost effective. Sensitivity analyses showed that the cost effectiveness was particularly sensitive to assumed herd benefits and vaccine efficacy estimates.

CONCLUSION

Under base case assumptions it is unlikely that a pneumococcal vaccination programme aimed at risk groups could be considered cost effective. Uncertainty could be substantially reduced by establishing the effectiveness of the 13 valent pneumococcal conjugate vaccine against non-bacteraemic pneumococcal pneumonia, particularly in at risk groups.

Costs and effectiveness of neonatal male circumcision

OBJECTIVE

To evaluate the expected change in the prevalence of male circumcision (MC)-reduced infections and resulting health care costs associated with continued decreases in MC rates. During the past 20 years, MC rates have declined from 79% to 55%, alongside reduced insurance coverage.

DESIGN

We used Markov-based Monte Carlo simulations to track men and women throughout their lifetimes as they experienced MC procedure-related events and MC-reduced infections and accumulated associated costs. One-way and probabilistic sensitivity analyses were used to evaluate the impact of uncertainty.

SETTING

United States.

PARTICIPANTS

Birth cohort of men and women.

INTERVENTION

Decreased MC rates (10% reflects the MC rate in Europe, where insurance coverage is limited).

OUTCOMES MEASURED

Lifetime direct medical cost (2011 US$) and prevalence of MC-reduced infections.

RESULTS

Reducing the MC rate to 10% will increase lifetime health care costs by $407 per male and $43 per female. Net expenditure per annual birth cohort (including procedure and complication costs) is expected to increase by $505 million, reflecting an increase of $313 per forgone MC. Over 10 annual cohorts, net present value of additional costs would exceed $4.4 billion. Lifetime prevalence of human immunodeficiency virus infection among males is expected to increase by 12.2% (4843 cases), high- and low-risk human papillomavirus by 29.1% (57 124 cases), herpes simplex virus type 2 by 19.8% (124 767 cases), and infant urinary tract infections by 211.8% (26 876 cases). Among females, lifetime prevalence of bacterial vaginosis is expected to increase by 51.2% (538 865 cases), trichomoniasis by 51.2% (64 585 cases), high-risk human papillomavirus by 18.3% (33 148 cases), and low-risk human papillomavirus by 12.9% (25 837 cases). Increased prevalence of human immunodeficiency virus infection among males represents 78.9% of increased expenses.

CONCLUSION

Continued decreases in MC rates are associated with increased infection prevalence, thereby increasing medical expenditures for men and women.

Years of potential life lost due to HIV infection and associated factors based on national HIV surveillance data in Latvia, 1991-2010

BACKGROUND

Latvia is still experiencing one of the highest human immunodeficiency virus (HIV) mortality rates in the European Union, and HIV is the 6(th) leading cause of death among young adults (15-39 y) in the country. The aim of the study was to determine the years of potential life lost (YPLL) as an indicator of premature mortality and the associated factors among people living with HIV (PLH) in Latvia.

METHODS

Data from the National Registry of HIV/AIDS Cases was used for the time period 1991-2010. Data on 738 deaths were analysed. The cut-off age for YPLL calculations was 65 y. Univariable analysis was done using Mann-Whitney and Kruskal-Wallis tests. A linear regression model was constructed for determining the independent effects of the particular factors on the number of YPLL.

RESULTS

The total number of YPLL due to HIV in Latvia was 21,097 (50.4/100,000 general population; 511.1/1000 PLH). Each PLH who died had lost 28.8 YPLL on average. The numbers of YPLL reflect the population groups most affected by the HIV epidemic (young men, non-ethnic Latvians, living in the capital city, and being infected via drug injection). Our regression model indicated that among deceased PLH, non-Latvian ethnicity and injecting drug use as the mode of HIV transmission were associated with an additional 2.4 (p = 0.003) and 5.7 (p < 0.001) average YPLL, respectively.

CONCLUSIONS

A considerable number of years of potential life have been lost in Latvia due to HIV. YPLL is significantly associated with ethnicity and mode of HIV transmission.

Shifting sands: changing regional and gender-specific patterns of HIV/AIDS mortality in Canada, 1987 to 2008

OBJECTIVE

To assess patterns of HIV-related mortality by period, gender and age group in Canada from 1987 to 2008.

METHODS

We applied standard demographic techniques to assess changes in HIV/AIDS mortality over five time periods: 1987-1991, 1992-1996, 1997-2001, 2002-2006, and 2007-2008. HIV/AIDS-related mortality was based on deaths in which HIV infection or AIDS was reported as the underlying cause of death. Population figures were obtained from annual estimates. Age-, sex- and province-specific crude and standardized HIV/AIDS mortality rates and ratios were used to examine changes in mortality.

RESULTS

In the period from 1987 to 2008, there were 17,287 HIV/AIDS-related deaths; of these, 15,587 (90.2%) occurred among men and 1,700 (9.8%) among women. Standardized and age-specific death rates were generally higher in men than women. Among men, rates of mortality were highest in Quebec and British Columbia; and among women, rates increased over time in British Columbia and the Prairies and decreased in Quebec. In general, rates of death were highest in 1992-1996 and lowest in the latest period.

CONCLUSION

We observed a sharp decline in mortality rates with the introduction of HAART; however, the rates were higher among men in Quebec and British Columbia and among women in British Columbia, Quebec and the Prairies.

Using laboratory surveillance data to estimate engagement in care among persons living with HIV in Los Angeles County, 2009

Poor engagement in HIV care has been associated with delayed access to antiretroviral treatment and increased HIV transmission. Using viral load (VL) results from HIV laboratory surveillance data to conduct longitudinal and cross-sectional analyses, we examined linkage to care, retention in care, and their associated factors in 37,325 persons living with HIV (PLWH) in Los Angeles County (LAC). Linkage to care was considered timely if a VL test result was present ≤3 months of diagnosis. Successful retention in care was defined as having two or more VL test results ≥90 days apart during 2009. Of 6841 persons newly diagnosed with HIV in 2007-2009, 67% were linked to care within 3 months of diagnosis. Factors associated with delayed linkage to care included being African American, Latino, and Asian/Pacific Islander (adjusted hazard ratio [AHR]=0.81; 95% CI=0.75-0.87, AHR=0.83; 95% CI=0.77-0.89, AHR=0.82; 95% CI=0.71-0.94, respectively). Of the 37,325 PLWH, 52% were retained in care during 2009. Factors associated with lack of retention in care included injection drug use (adjusted prevalence ratio [APR]=0.88; 95% CI=0.84-0.93), incarceration at diagnosis (APR=0.56; 95% CI=0.51-0.61), being diagnosed in pre-highly active antiretroviral therapy (HAART) era (APR=0.94; 95% CI=0.92-0.96) or at a public facility (APR=0.97; 95% CI=0.95-1.00), age <45 years (APR=0.87; 95% CI=0.86-0.89), and having concurrent HIV/AIDS diagnoses (APR=0.94; 95% CI=0.92-0.96). This study demonstrates the value of using VL surveillance data to monitor engagement in care among PLWH, and its potential to improve linkage and retention efforts where disparities in care are observed.

HIV infection and older Americans: the public health perspective

HIV disease is often perceived as a condition affecting young adults. However, approximately 11% of new infections occur in adults aged 50 years or older. Among persons living with HIV disease, it is estimated that more than half will be aged 50 years or older in the near future. In this review, we highlight issues related to HIV prevention and treatment for HIV-uninfected and HIV-infected older Americans, and outline unique considerations and emerging challenges for public health and patient management in these 2 populations.

Socioeconomic Status and Survival of People with Human Immunodeficiency Virus Infection before and after the Introduction of Highly Active Antiretroviral Therapy: A Systematic Literature Review

BACKGROUND

Human immunodeficiency virus/acquired immunodeficiency disease syndrome-associated mortality contributes considerably to overall mortality rates among adults in the United States. The purpose of this review is to systematically examine conceptual approaches that have been used to evaluate the association between socioeconomic status of people infected with human immunodeficiency virus and their survival and summarize existing evidence regarding the association between socioeconomic status and mortality due to human immunodeficiency virus/acquired immunodeficiency disease syndrome.

METHODS

We systematically retrieved neighborhood and individual-level studies of acquired immunodeficiency disease syndrome-related or all-cause mortality among patients diagnosed with human immunodeficiency virus that reported original data and analyzed socioeconomic status as a predictor of mortality.

RESULTS

We included 21 studies (19 cohort and 2 case-control studies). Heterogeneity in both the conceptual approaches to socioeconomic status measurements and selection of variables for the adjustment of the measure of association precluded meta-analysis of the results. Six studies observing populations before the introduction of highly active antiretroviral therapy found that socioeconomic status was not associated with human immunodeficiency virus/acquired immunodeficiency disease syndrome mortality. In the post- highly active antiretroviral therapy period socioeconomic status was inconsistently associated with Human immunodeficiency virus/acquired immunodeficiency disease syndrome mortality risk in studies adjusting for highly active antiretroviral therapy use.

CONCLUSION

Further studies considering multilevel socioeconomic status measurements and controlling for treatment and clinical variables are needed to enhance understanding of the role of socioeconomic gradients on human immunodeficiency virus outcomes.

Concurrent sexual partnerships among African American women in Philadelphia: results from a qualitative study

BACKGROUND

African American women are disproportionately affected by HIV/AIDS. Concurrent sexual partnerships may contribute to racial disparities in HIV infection. Little is known about attitudes and practices related to concurrency among African American women, or the social, structural and behavioural factors influencing concurrency.

METHODS

We recruited 19 heterosexual African American women engaging in concurrent sexual partnerships from a public clinic in Philadelphia in 2009. We conducted interviews exploring social norms, attitudes and practices about concurrency, and the structural, social and behavioural factors influencing concurrent sexual partnerships, guided by grounded theory.

RESULTS

Seventeen women reported one main and one or more non-main partners; two reported no main partners. Many women used condoms more frequently with non-main than main partners, noting they trust main partners more than non-main partners. Social factors included social normalisation of concurrency, inability to negotiate partners' concurrent partnerships, being unmarried, and not trusting partners. Lack of trust was the most commonly cited reason that women engaged in concurrent partnerships. Structural factors included economic dependence on partners, partners' dependence on women for economic support and incarceration that interrupted partnerships. Behavioural factors included alcohol and cocaine use.

CONCLUSIONS

Social, structural and behavioural factors strongly influenced these African American women's concurrent sexual partnerships. Many HIV interventions disseminated by the CDC focus largely on behavioural factors and may fail to address the social and structural factors influencing African American women's sexual networks. Novel HIV prevention interventions that address the social determinants of African American women's HIV risks are urgently needed.

Longitudinal Pediatric Palliative Care: Quality of Life & Spiritual Struggle (FACE): design and methods

As life expectancy increases for adolescents ever diagnosed with AIDS due to treatment advances, the optimum timing of advance care planning is unclear. Left unprepared for end-of-life (EOL) decisions, families may encounter miscommunication and disagreements, resulting in families being charged with neglect, court battles and even legislative intervention. Advanced care planning (ACP) is a valuable tool rarely used with adolescents. The Longitudinal Pediatric Palliative Care: Quality of Life & Spiritual Struggle study is a two-arm, randomized controlled trial assessing the effectiveness of a disease specific FAmily CEntered (FACE) advanced care planning intervention model among adolescents diagnosed with AIDS, aimed at relieving psychological, spiritual, and physical suffering, while maximizing quality of life through facilitated conversations about ACP. Participants will include 130 eligible dyads (adolescent and family decision-maker) from four urban cities in the United States, randomized to either the FACE intervention or a Healthy Living Control. Three 60-minute sessions will be conducted at weekly intervals. The dyads will be assessed at baseline as well as 3-, 6-, 12-, and 18-month post-intervention. The primary outcome measures will be in congruence with EOL treatment preferences, decisional conflict, and quality of communication. The mediating and moderating effects of threat appraisal, HAART adherence, and spiritual struggle on the relationships among FACE and quality of life and hospitalization/dialysis use will also be assessed. This study will be the first longitudinal study of an AIDS-specific model of ACP with adolescents. If successful, this intervention could quickly translate into clinical practice.

A systematic review of HIV/AIDS survival and delayed diagnosis among Hispanics in the United States

HIV/AIDS disproportionately affects Hispanics. Our objective was to determine the risk of late diagnosis and rate of survival after HIV/AIDS diagnosis among Hispanics compared to other racial/ethnic groups. We performed a systematic review of the PubMed database for peer-reviewed articles published between January 2000 and September 2010. Primary outcomes included survival after HIV/AIDS diagnosis and delayed diagnoses. The definition of delayed diagnosis varied by study, ranging from concurrent HIV/AIDS diagnosis to diagnosis of AIDS within 3 years of HIV diagnosis. We found that Hispanics are at significantly greater risk for delayed diagnosis than non-Hispanic whites. Hispanic males and foreign-born Hispanics had the highest risk of late diagnosis. Available data on survival were heterogeneous, with better outcomes in some Hispanic subgroups than in others. Survival after antiretroviral initiation was similar between Hispanics and Whites. These findings emphasize the need for culturally-sensitive strategies to promote timely diagnosis of HIV infection among Hispanics and to examine the health outcomes and needs of high risk Hispanic subgroups.

Trends in birth weight and gestational age for infants born to HIV-infected, antiretroviral treatment-naive women in Malawi

BACKGROUND

We analyzed birth outcomes among infants of treatment-naive, HIV-infected women from a series of mother-to-child transmission of HIV studies in Blantyre, Malawi.

METHODS

Data from 6 prospective studies at 1 research site were analyzed. Mean birth weight (BW) and gestational age (GA), and frequency of low birth weight (LBW; <2500 g) and preterm (PT) birth (GA < 37 weeks) were estimated. We assessed risk factors for LBW and PT birth using mixed-effects logistic regression. Adjusted odds ratios (AOR) and 95% confidence intervals from earlier studies (1989-1994) and later studies (2000-2007) are presented separately.

RESULTS

The analysis included 8874 HIV-exposed infants. Mean BW and GA ranged from 2793 to 3079 g, and from 37.8 to 39.0 weeks. Greater maternal age was consistently (during both the early and late periods) associated with lower odds of LBW and PT birth; AOR (95% confidence intervals) for both outcomes in the early and late periods, respectively, were 0.98 (0.96-1.00) and 0.97 (0.95-0.99). Female infant gender was consistently associated with higher odds of PT birth during both periods and with higher odds of LBW during the later period. During the early period, higher maternal education was associated with lower odds of LBW (AOR 0.67 [0.48-0.95]) and PT birth (AOR 0.70 [0.51-0.95]), and later birth year was associated with lower odds of PT birth (AOR 0.35 [0.19-0.70]).

CONCLUSIONS

BW and GA remained stable within each time period. This analysis provides important baseline information for monitoring HIV treatment effects on birth outcomes. Modifiable factors affecting BW and GA should continue to be explored.

Late entry into HIV care: lessons from Brazil, 2003 to 2006

Background

To ascertain the population rates and proportion of late entry into HIV care, as well as to determine whether such late entry correlates with individual and contextual factors.

Methods

Data for the 2003–2006 period in Brazil were obtained from public health records. A case of late entry into HIV care was defined as one in which HIV infection was diagnosed at death, one in which HIV infection was diagnosed after the condition of the patient had already been aggravated by AIDS-related diseases, or one in which the CD4⁺ T-cell count was ≤ 200 cells/mm³ at the time of diagnosis. We also considered extended and stricter sets of criteria (in which the final criterion was ≤ 350 cells/mm³ and ≤ 100 cells/mm³, respectively). The estimated risk ratio was used in assessing the effects of correlates, and the population rates (per 100,000 population) were calculated on an annual basis.

Results

Records of 115,369 HIV-infected adults were retrieved, and 43.6% (50,358) met the standard criteria for late entry into care. Diagnosis at death accounted for 29% (14,457) of these cases. Late entry into HIV care (standard criterion) was associated with certain individual factors (sex, age, and transmission category) and contextual factors (region with less economic development/increasing incidence of AIDS, lower local HIV testing rate, and smaller municipal population). Use of the extended criteria increased the proportion of late entry by 34% but did not substantially alter the correlations analyzed. The overall population rate of late entry was 9.9/100,000 population, specific rates being highest for individuals in the 30–59 year age bracket, for men, and for individuals living in regions with greater economic development/higher HIV testing rates, collectively accounting for more than half of the cases observed.

Conclusions

Although the high proportion of late entry might contribute to spreading the AIDS epidemic in less developed regions, most cases occurred in large cities, with broader availability of HIV testing, and in economically developed regions.

Evaluation of vitamin D levels among HIV-infected patients in New York City

Few studies have examined the vitamin D status in HIV-infected patients. A cross-sectional retrospective chart review of 2992 HIV-infected patients was conducted from 9/2008 to 5/2009. A total of 274 adult patients had 25-hydroxyvitamin D [25(OH)D] obtained by radioimmunoassay. None was receiving vitamin D (vitD) supplements. Vitamin D status was defined as the following: vitD deficiency (vitDd) as 25(OH)D <25 nmol/liter, vitD insufficiency (vitDi) as 25(OH)D 25-74 nmol/liter, and vitD optimal (vitDo) as 25(OH)D ≥75 nmol/liter. We analyzed demographic/laboratory data. vitDd, vitDi, and vitDo were 21.2% (58 patients, 58/274), 68.6% (188 patients, 188/274), and 10.2% (28 patients, 28/274), respectively. There were significant racial differences. Blacks were 60.3% (35 patients, 35/58), 40.4% (76 patients, 76/188), and 28.6 % (8 patients, 8/28) in vitDd, vitDi, and vitDo, respectively, p=0.002. CD4 T cell count was not different in these three groups. However, HIV viral load was significantly different. Median log (10) HIV viral load was 2.31 with IQR 1.70-409, 1.70 with IQR 1.70-2.96, and 1.70 with IQR 1.70-2.78 in vitDd, vitDi, and vitDo, respectively, p=0.039. Multivariate logistic regression analysis showed that black race [odd ratio (OR) 4.108, 95% confidence interval (CI) 1.462-11.543, p=0.007] and HIV viral load>50 copies/ml (OR 2.396, 95% CI 1.120-5.127, p=0.024) were significantly associated with vitamin D deficiency. Vitamin D deficiency was highly prevalent in HIV-infected patients. Detectable HIV viremia and dark skin (black ethnicity) were significantly associated with vitamin D deficiency. Evaluation of vitamin D status in HIV-infected patients should be considered and further studies are needed to define the effects of vitamin D.

Plasma raltegravir exposure influences the antiviral activity and selection of resistance mutations

Raltegravir (RAL) resistance is associated with the selection of integrase mutations at positions 92, 143, 148, and/or 155. A substantial proportion of RAL failures, however, occurs in the absence of these changes. An examination of RAL plasma concentrations may help in interpreting this observation. All early RAL virological failures seen at 22 clinics in Spain during 2009 were identified. HIV integrase sequences and RAL plasma trough concentrations (C(t)) were examined. A total of 106 patients experiencing virological failure on RAL were identified. Only the earliest sample on failure was examined. Integrase sequences could be obtained for 89 (84%), of whom 30 (33.7%) depicted primary RAL resistance mutations (15 N155H, eight Q148H/R, three Y143R, one E92Q, and three more than one of them). Another nine (10.1%) patients showed only secondary changes. The remaining 50 RAL early failures (56.2%) did not select any integrase change. RAL C(t) could be measured in 66 patients at failure and in 21 of them before failure. In a control group of 37 patients with viral suppression on RAL, detectable plasma levels were seen in all cases, with greater median RAL C(t) than in failures, either at the time of viral rebound (p<0.001) or before it (p=0.055). Moreover, median C(t) at the time of failure was greater in patients selecting primary RAL resistance mutations than in the rest of the failures (p<0.001). Undetectable RAL C(t) was seen only in patients failing RAL without integrase resistance mutations (64.1% of them). RAL failures in the absence of integrase resistance mutations mainly reflect poor drug compliance.

Projected life expectancy of people with HIV according to timing of diagnosis

BACKGROUND AND OBJECTIVES

Effective antiretroviral therapy (ART) has contributed greatly toward survival for people with HIV, yet many remain undiagnosed until very late. Our aims were to estimate the life expectancy of an HIV-infected MSM living in a developed country with extensive access to ART and healthcare, and to assess the effect of late diagnosis on life expectancy.

METHODS

A stochastic computer simulation model of HIV infection and the effect of ART was used to estimate life expectancy and determine the distribution of potential lifetime outcomes of an MSM, aged 30 years, who becomes HIV positive in 2010. The effect of altering the diagnosis rate was investigated.

RESULTS

Assuming a high rate of HIV diagnosis (median CD4 cell count at diagnosis, 432  cells/μl), projected median age at death (life expectancy) was 75.0 years. This implies 7.0 years of life were lost on average due to HIV. Cumulative risks of death by 5 and 10 years after infection were 2.3 and 5.2%, respectively. The 95% uncertainty bound for life expectancy was (68.0,77.3) years. When a low diagnosis rate was assumed (diagnosis only when symptomatic, median CD4 cell count 140  cells/μl), life expectancy was 71.5 years, implying an average 10.5 years of life lost due to HIV.

CONCLUSION

If low rates of virologic failure observed in treated patients continue, predicted life expectancy is relatively high in people with HIV who can access a wide range of antiretrovirals. The greatest risk of excess mortality is due to delays in HIV diagnosis.

Cancer screening in patients infected with HIV

Non-AIDS-defining cancers are a rising health concern among HIV-infected patients. Cancer screening is now an important component of health maintenance in HIV clinical practice. The decision to screen an HIV-infected patient for cancer should include an assessment of individualized risk for the particular cancer, life expectancy, and the harms and benefits associated with the screening test and its potential outcome. HIV-infected patients are at enhanced risk of several cancers compared to the general population; anal cancer, hepatocellular carcinoma, Hodgkin's lymphoma, and lung cancer all have good evidence demonstrating an enhanced risk in HIV-infected persons. A number of cancer screening interventions have shown benefit for specific cancers in the general population, but data on the application of these tests to HIV-infected persons are limited. Here we review the epidemiology and background literature relating to cancer screening interventions in HIV-infected persons. We then use these data to inform a conceptual model for evaluating HIV-infected patients for cancer screening.

Commentary: thirty years of AIDS in America: a story of infinite hope

The year 2011 marks the thirtieth anniversary of the first case reports in the United States of what we now know to be end-stage HIV disease. This chronological milestone provides an opportunity to reflect upon the changing context of the American HIV/AIDS epidemic. Using two seminal documents as a framework, the 1986 Institute of Medicine Report, "Confronting AIDS," and the 2010 National HIV/AIDS Strategy, this descriptive analysis details our accomplishments in addressing the domestic U.S. epidemic and outlines what remains to be done on the long road to eradication of HIV disease. The past three decades have witnessed tremendous biomedical and behavioral advances in preventing, diagnosing, and treating HIV disease. However, to fully realize the promise of these scientific advances, such that we achieve the vision of the National HIV/AIDS Strategy, we must develop effective strategies to surmount a number of salient challenges, including: unbalanced combinations of prevention interventions; programs that are not of adequate scale to achieve population-level results; systems of service delivery that do not function in an integrated fashion; and social and economic structures that increase the vulnerability of populations who are at risk for or living with HIV disease.

Enhancing HIV communication between parents and children: efficacy of the Parents Matter! Program

We examine efficacy of the Parents Matter! Program (PMP), a program to teach African-American parents of preadolescents sexual communication and HIV-prevention skills, through a multicenter, randomized control trial. A total of 1115 parent-child participants were randomized to one of three intervention arms (enhanced, brief, control). Percentages and 95% confidence intervals compare parents' perception of child readiness to learn about sexual issues, communication effectiveness, and dyad concordance from baseline to 12 months postintervention. Wilcoxon rank sum tests compare the changes in scores measuring communication content in HIV/AIDS, abstinence, and condom use. Compared to control, parents in the enhanced arm increased perception of child readiness to learn about sex (16% vs. 29%; p < .001), and a greater proportion of parent-child dyads reported concordant responses on communication topics: HIV/AIDS (15%, 95% CI = 8-21%; p < .001), abstinence (13%, 95% CI = 7-20%; p < .001), condoms (15%, 95% CI = 9-22%; p < .001). Increases in communication scores in HIV/AIDS, abstinence, and condom use were greater in the enhanced arm than control (p < 0.01). We conclude that the enhanced PMP can help parents educate children about HIV and prepare children to avoid sexual risk.

State variation in AIDS drug assistance program prescription drug coverage for modifiable cardiovascular risk factors

BACKGROUND

In the United States, mortality from cardiovascular disease has become increasingly common among HIV-infected persons. One-third of HIV-infected persons in care may rely on state-run AIDS Drug Assistance Programs (ADAPs) for cardiovascular disease-related prescription drugs. There is no federal mandate regarding ADAP coverage for non-HIV medications.

OBJECTIVE

To assess the consistency of ADAP coverage for type 2 diabetes, hypertension, hyperlipidemia, and smoking cessation using clinical guidelines as the standard of care.

DESIGN

Cross-sectional survey of 53 state and territorial ADAP formularies.

MAIN MEASURES

ADAPs covering all first-line drugs for a cardiovascular risk factor were categorized as "consistent" with guidelines, while ADAPs covering at least one first-line drug, but not all, for a cardiovascular risk factor, were categorized as "partially consistent". ADAPs without coverage were categorized as "no coverage".

KEY RESULTS

Of 53 ADAPs, four (7.5%) provided coverage consistent with guidelines (coverage for all first-line drugs) for all four cardiovascular risk factors. Thirteen (24.5%) provided no coverage for all four risk factors. Thirty-six (68%) provided at least partially consistent coverage for at least one surveyed risk factor. State ADAPs provided coverage consistent with guidelines most frequently for type 2 diabetes (28%), followed by hypertension (25%), hyperlipidemia (15%) and smoking cessation (8%). Statins (66%) were most commonly covered and nicotine replacement therapies (9%) least often. Many ADAPs provided no first-line treatment coverage for hypertension (60%), type 2 diabetes (51%), smoking cessation (45%), and hyperlipidemia (32%).

CONCLUSIONS

Consistency of ADAP coverage with guidelines for the surveyed cardiovascular risk factors varies widely. Given the increasing lifespan of HIV-infected persons and restricted ADAP budgets, we recommend ADAP coverage be consistent with guidelines for cardiovascular risk factors.