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Lundgren JD, Babiker AG, Sharma S, Grund B, Phillips AN, Matthews G, Kan VL, Aagaard B, Abo I, Alston B, Arenas-Pinto A, Avihingsanon A, Badal-Faesen S, Brites C, Carey C, Casseb J, Clarke A, Collins S, Corbelli GM, Dao S, Denning ET, Emery S, Eriobu N, Florence E, Furrer H, Fätkenheuer G, Gerstoft J, Gisslén M, Goodall K, Henry K, Horban A, Hoy J, Hudson F, Azwa RISR, Kedem E, Kelleher A, Kityo C, Klingman K, Rosa AL, Leturque N, Lifson AR, Losso M, Lutaakome J, Madero JS, Mallon P, Mansinho K, Filali KME, Molina JM, Murray DD, Nagalingeswaran K, Nozza S, Ormaasen V, Paredes R, Peireira LC, Pillay S, Polizzotto MN, Raben D, Rieger A, Sanchez A, Schechter M, Sedlacek D, Staub T, Touloumi G, Turner M, Madruga JV, Vjecha M, Wolff M, Wood R, Zilmer K, Lane HC, Neaton JD. Long-Term Benefits from Early Antiretroviral Therapy Initiation in HIV Infection. NEJM Evid 2023; 2:10.1056/evidoa2200302. [PMID: 37213438 PMCID: PMC10194271 DOI: 10.1056/evidoa2200302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
BACKGROUND For people with HIV and CD4+ counts >500 cells/mm3, early initiation of antiretroviral therapy (ART) reduces serious AIDS and serious non-AIDS (SNA) risk compared with deferral of treatment until CD4+ counts are <350 cells/mm3. Whether excess risk of AIDS and SNA persists once ART is initiated for those who defer treatment is uncertain. METHODS The Strategic Timing of AntiRetroviral Treatment (START) trial, as previously reported, randomly assigned 4684 ART-naive HIV-positive adults with CD4+ counts .500 cells/mm3 to immediate treatment initiation after random assignment (n = 2325) or deferred treatment (n= 2359). In 2015, a 57% lower risk of the primary end point (AIDS, SNA, or death) for the immediate group was reported, and the deferred group was offered ART. This article reports the follow-up that continued to December 31, 2021. Cox proportional-hazards models were used to compare hazard ratios for the primary end point from randomization through December 31, 2015, versus January 1, 2016, through December 31, 2021. RESULTS Through December 31, 2015, approximately 7 months after the cutoff date from the previous report, the median CD4+ count was 648 and 460 cells/mm3 in the immediate and deferred groups, respectively, at treatment initiation. The percentage of follow-up time spent taking ART was 95% and 36% for the immediate and deferred groups, respectively, and the time-averaged CD4+ difference was 199 cells/mm3. After January 1, 2016, the percentage of follow-up time on treatment was 97.2% and 94.1% for the immediate and deferred groups, respectively, and the CD4+ count difference was 155 cells/mm3. After January 1, 2016, a total of 89 immediate and 113 deferred group participants experienced a primary end point (hazard ratio of 0.79 [95% confidence interval, 0.60 to 1.04] versus hazard ratio of 0.47 [95% confidence interval, 0.34 to 0.65; P<0.001]) before 2016 (P=0.02 for hazard ratio difference). CONCLUSIONS Among adults with CD4+ counts >500 cells/mm3, excess risk of AIDS and SNA associated with delaying treatment initiation was diminished after ART initiation, but persistent excess risk remained. (Funded by the National Institute of Allergy and Infectious Diseases and others.).
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Affiliation(s)
- Jens D Lundgren
- CHIP Centre of Excellence for Health, Immunity, and Infections, Department of Infectious Diseases, Rigshospitalet, Copenhagen
| | - Abdel G Babiker
- Medical Research Council Clinical Trials Unit, University College London, London
| | - Shweta Sharma
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis
| | - Birgit Grund
- School of Statistics, University of Minnesota, Minneapolis
| | | | | | | | - Bitten Aagaard
- CHIP Centre of Excellence for Health, Immunity, and Infections, Department of Infectious Diseases, Rigshospitalet, Copenhagen
| | - Inka Abo
- Helsinki University Central Hospital, Helsinki
| | - Beverly Alston
- Division of AIDS, National Institute of Allergy and Infectious Diseases, Bethesda, MD
| | | | | | - Sharlaa Badal-Faesen
- Clinical HIV Research Unit, Department of Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg
| | - Carlos Brites
- Hospital Universitario Professor Edgard Santos, School of Medicine, Federal University of Bahia, Salvador, Brazil
| | | | - Jorge Casseb
- Laboratory of Medical Investigation - LIM56, Faculty of Medicine, Department of Dermatology, University of São Paulo, São Paulo
| | - Amanda Clarke
- Royal Sussex County Hospital, Brighton, United Kingdom
| | | | | | - Sounkalo Dao
- Mali-National Institute of Allergy and Infectious Diseases HIV Research Initiative, Bamako, Mali
| | - Eileen T Denning
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis
| | | | | | | | - Hansjakob Furrer
- Department of Infectious Diseases, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Gerd Fätkenheuer
- Klinik I für Innere Medizin der Universität zu Köln, Cologne, Germany
| | - Jan Gerstoft
- Rigshospitalet, Infektionsmedicinsk ambulatorium 8622, Copenhagen
| | | | - Katharine Goodall
- Medical Research Council Clinical Trials Unit, University College London, London
| | - Keith Henry
- Hennepin Health Research Institute, Minneapolis
| | | | - Jennifer Hoy
- Department of Infectious Diseases, The Alfred Hospital and Monash University, Melbourne, VIC, Australia
| | - Fleur Hudson
- Medical Research Council Clinical Trials Unit, University College London, London
| | | | | | | | - Cissy Kityo
- Joint Clinical Research Centre, Kampala, Uganda
| | - Karin Klingman
- Division of AIDS, National Institute of Allergy and Infectious Diseases, Bethesda, MD
| | | | | | | | - Marcelo Losso
- Hospital General de Agudos J.M. Ramos Mejia, Buenos Aires
| | | | - Juan Sierra Madero
- Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City
| | - Patrick Mallon
- Centre for Experimental Pathogen Host Research, University College Dublin, Dublin
| | | | | | | | - Daniel D Murray
- CHIP Centre of Excellence for Health, Immunity, and Infections, Department of Infectious Diseases, Rigshospitalet, Copenhagen
| | - Kumarasamy Nagalingeswaran
- Voluntary Health Services, Infectious Diseases Medical Centre, Chennai Antiviral Research and Treatment, Clinical Research Site, Chennai, India
| | | | | | - Roger Paredes
- Hospital Universitari Germans Trias i Pujol, Barcelona
| | | | - Sandy Pillay
- Durban International Clinical Research Site, Durban, South Africa
| | - Mark N Polizzotto
- Clinical Hub for Interventional Research, College of Health and Medicine, The Australian National University, Canberra, ACT, Australia
| | - Dorthe Raben
- CHIP Centre of Excellence for Health, Immunity, and Infections, Department of Infectious Diseases, Rigshospitalet, Copenhagen
| | | | | | | | | | | | - Giota Touloumi
- Medical School, National and Kapodistrian University of Athens, Athens
| | | | | | | | - Marcelo Wolff
- Hospital Clínico San Borja Arriarán, Fundación Arriarán, Santiago, Chile
| | - Robin Wood
- Desmond Tutu Health Foundation, Cape Town, South Africa
| | - Kai Zilmer
- West Tallinn Central Hospital Infectious Diseases, Tallinn, Estonia
| | - H Clifford Lane
- National Institute of Allergy and Infectious Diseases, Bethesda, MD
| | - James D Neaton
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis
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Lifson AR, Hailemichael A, Workneh S, MacLehose RF, Horvath KJ, Hilk R, Sites A, Slater L, Shenie T. A three-year randomized community trial of community support workers in rural Ethiopia to promote retention in HIV care. AIDS Care 2022; 34:1506-1512. [PMID: 35195481 PMCID: PMC9395549 DOI: 10.1080/09540121.2022.2029819] [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: 08/03/2021] [Accepted: 01/12/2022] [Indexed: 01/26/2023]
Abstract
Retention in care is a major challenge for global AIDS control, including sub-Saharan Africa. In a large Ethiopian region, we evaluated an intervention where HIV positive community support workers (CSWs) provided HIV health education, personal counseling and social support for HIV patients new to care. We enrolled 1,799 patients recently entering care from 32 hospitals and health centers, randomized to intervention or control sites. Dates of all clinic visits, plus deaths or transfers were abstracted from HIV medical records. Primary outcomes were gap in clinical care (>90 days from a missed clinical or drug pickup appointment) and death. For 36 months of follow-up, and for the first 12 months after enrollment, weighted risk differences [RD] between treatment arms were modest and non-significant for gap in clinical care, death or either outcome. Through 36 months, 624 of 980 controls and 469 of 819 intervention participants had gaps in clinical care (RD = -5.5%, 95% confidence interval [CI] = -17.9%, 7.0%); 79 controls and 82 intervention participants died (RD = 2.5% 95% CI = -1.7%, 6.8%). Factors including HIV stigma and a volatile political climate may have attenuated the advantages we anticipated, demonstrating how benefits of CSW interventions may depend upon psychosocial, clinical and structural factors particular to specific community settings.
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Affiliation(s)
- Alan R Lifson
- Division of Epidemiology and Community Health, University of Minnesota, Minneapolis, MN, USA
| | - Abera Hailemichael
- Ethiopian Office, National Alliance of State and Territorial AIDS Directors, Addis Ababa, Ethiopia
| | - Sale Workneh
- Ethiopian Office, National Alliance of State and Territorial AIDS Directors, Addis Ababa, Ethiopia
| | - Richard F MacLehose
- Division of Epidemiology and Community Health, University of Minnesota, Minneapolis, MN, USA
| | - Keith J Horvath
- Division of Epidemiology and Community Health, University of Minnesota, Minneapolis, MN, USA
- Department of Psychology, San Diego State University, San Diego, CA, USA
| | - Rose Hilk
- Division of Epidemiology and Community Health, University of Minnesota, Minneapolis, MN, USA
| | - Anne Sites
- Global Program, National Alliance of State and Territorial AIDS Directors, Washington, DC, USA
| | - Lucy Slater
- Global Program, National Alliance of State and Territorial AIDS Directors, Washington, DC, USA
| | - Tibebe Shenie
- Ethiopian Office, National Alliance of State and Territorial AIDS Directors, Addis Ababa, Ethiopia
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Lifson AR, Workneh S, Hailemichael A, MacLehose RF, Horvath KJ, Hilk R, Sites A, Shenie T. Disclosure of HIV status among patients new to HIV care in Southern Ethiopia: role of perceived social support and other factors. AIDS Care 2020; 33:1133-1138. [PMID: 32613851 DOI: 10.1080/09540121.2020.1785999] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Reports from Sub-Saharan Africa, with a large HIV-infected population, vary widely in how often HIV status is disclosed to others, including spouses and other partners. We surveyed 1799 Ethiopian HIV patients newly enrolled in care within the previous 3 months at one of 32 local hospitals and health centers about disclosure of HIV status and two perceived social support domains: emotional/informational (EI) and tangible assistance (TA) support. Disclosure to another person was reported by 1389 (77%) persons. Disclosure rates to specific persons were: spouses or other partners = 74%; mothers = 24%; fathers = 16%; children = 26%; other family members = 37%; friends = 19%, and neighbors/other community members = 13%. Disclosure to another person was associated with higher social support scores on both EI and TA domains, marriage, and a longer time knowing HIV status. In multivariate adjusted models, disclosure to any person, as well as disclosure specifically to a spouse or partner, were associated with higher EI and higher TA social support scores. Provision of knowledgeable and emotionally supportive assistance can be an important factor in facilitating HIV disclosure. Helping persons with HIV decide who to disclose to and how to do so in the most positive manner is an essential component of HIV care and support.
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Affiliation(s)
- Alan R Lifson
- Division of Epidemiology and Community Health, University of Minnesota, Minneapolis, MN, USA
| | - Sale Workneh
- National Alliance of State and Territorial AIDS Directors, Ethiopian Office, Addis Ababa, Ethiopia
| | - Abera Hailemichael
- National Alliance of State and Territorial AIDS Directors, Ethiopian Office, Addis Ababa, Ethiopia
| | - Richard F MacLehose
- Division of Epidemiology and Community Health, University of Minnesota, Minneapolis, MN, USA
| | - Keith J Horvath
- Department of Psychology, San Diego State University, San Diego, CA, USA
| | - Rose Hilk
- Division of Epidemiology and Community Health, University of Minnesota, Minneapolis, MN, USA
| | - Anne Sites
- National Alliance of State and Territorial AIDS Directors, Global Program, Washington DC, USA
| | - Tibebe Shenie
- National Alliance of State and Territorial AIDS Directors, Ethiopian Office, Addis Ababa, Ethiopia
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Lifson AR, Workneh S, Hailemichael A, MacLehose RF, Horvath KJ, Hilk R, Fabian L, Sites A, Shenie T. A multi-site community randomized trial of community health workers to provide counseling and support for patients newly entering HIV care in rural Ethiopia: study design and baseline implementation. HIV Clin Trials 2018; 19:112-119. [PMID: 29688139 DOI: 10.1080/15284336.2018.1461999] [Citation(s) in RCA: 4] [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] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Although HIV therapy is delivered to millions globally, treatment default (especially soon after entering care) remains a challenge. Community health workers (CHWs) can provide many services for people with HIV, including in rural and resource-limited settings. OBJECTIVES We designed and implemented a 32 site community randomized trial throughout southern Ethiopia to assess an intervention using CHWs to improve retention in HIV care. METHODS Sixteen district hospital and 16 local health center HIV clinics were randomized 1:1 to be intervention or control sites. From each site, we enrolled adults newly entering HIV care. Participants at intervention sites were assigned a CHW who provided: HIV and health education; counseling and social support; and facilitated communication with HIV clinics. All participants are followed through three years with annual health surveys, plus HIV clinic record abstraction including clinic visit dates. CHWs record operational data about their client contacts. RESULTS 1799 HIV patients meeting inclusion criteria were enrolled and randomized: 59% were female, median age = 32 years, median CD4 + count = 263 cells/mm3, and 41% were WHO Stage III or IV. A major enrollment challenge was fewer new HIV patients initiating care at participating sites due to shortage of HIV test kits. At intervention sites, 71 CHWs were hired, trained and assigned to clients. In meeting with clients, CHWs needed to accommodate to various challenges, including HIV stigma, distance, and clients lacking cell phones. CONCLUSIONS This randomized community HIV trial using CHWs in a resource-limited setting was successfully launched, but required flexibility to adapt to unforeseen challenges.
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Affiliation(s)
- Alan R Lifson
- a Division of Epidemiology and Community Health , University of Minnesota , Minneapolis , MN , USA
| | - Sale Workneh
- b Ethiopian Office , National Alliance of State and Territorial AIDS Directors , Addis Ababa , Ethiopia
| | - Abera Hailemichael
- b Ethiopian Office , National Alliance of State and Territorial AIDS Directors , Addis Ababa , Ethiopia
| | - Richard F MacLehose
- a Division of Epidemiology and Community Health , University of Minnesota , Minneapolis , MN , USA
| | - Keith J Horvath
- a Division of Epidemiology and Community Health , University of Minnesota , Minneapolis , MN , USA
| | - Rose Hilk
- a Division of Epidemiology and Community Health , University of Minnesota , Minneapolis , MN , USA
| | - Lindsey Fabian
- a Division of Epidemiology and Community Health , University of Minnesota , Minneapolis , MN , USA
| | - Anne Sites
- c Global Program , National Alliance of State and Territorial AIDS Directors , Washington , DC , USA
| | - Tibebe Shenie
- b Ethiopian Office , National Alliance of State and Territorial AIDS Directors , Addis Ababa , Ethiopia
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Lifson AR, Workneh S, Shenie T, Ayana DA, Melaku Z, Bezabih L, Waktola HT, Dagne B, Hilk R, Winters KC, Slater L. Frequent Use of Khat, an Amphetamine-Like Substance, as a Risk Factor for Poor Adherence and Lost to Follow-Up Among Patients New to HIV Care in Ethiopia. AIDS Res Hum Retroviruses 2017; 33:995-998. [PMID: 28462628 DOI: 10.1089/aid.2016.0274] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Khat, a plant native to East Africa, has amphetamine-like psychoactive constituents, and is a potential risk factor for HIV infection. Chronic use can cause cognitive impairment and other mental disorders, raising concerns about effects on retention and adherence with HIV care. During 2013-2014, 322 Ethiopian patients newly enrolled at HIV clinics in Dire Dawa and Harar were surveyed about khat use and prospectively followed for 1 year; 9% died, 18% transferred care to other clinics, and 22% were lost to follow-up (LTFU) (no clinic visit for >3 months). Of 248 patients who received a 12-month follow-up survey, 37% used khat in the year after enrollment, with a median use of 60 h in a typical month. Those using khat ≥60 h/month (median among users) were more likely than others to be LTFU (31% vs. 16%, p = .014); those using khat ≥150 h/month (upper quartile) had 44% LTFU rates versus 16% for others (p = .002). Complete 3-day adherence (taking all doses) of antiretroviral therapy was reported by 77% of those using khat ≥60 h/month versus 95% of all others (p < .001), and 67% of those using khat ≥150 h/month versus 94% of others (p < .001). In two East African cities, where khat use is common, frequent use was a significant risk factor for higher 1-year LTFU and lower self-reported antiretroviral therapy adherence among people living with HIV entering HIV care. Where khat is widely utilized, interventions to promote either nonuse or reduced use are important as part of a comprehensive HIV care package and national HIV strategies.
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Affiliation(s)
- Alan R. Lifson
- Department of Epidemiology and Community Health, University of Minnesota, Minneapolis, Minnesota
| | - Sale Workneh
- Ethiopian Office, National Alliance of State and Territorial AIDS Directors, Addis Ababa, Ethiopia
| | - Tibebe Shenie
- Ethiopian Office, National Alliance of State and Territorial AIDS Directors, Addis Ababa, Ethiopia
| | | | - Zenebe Melaku
- International Center for AIDS Care and Treatment Program, Addis Ababa, Ethiopia
| | - Lemlem Bezabih
- Ethiopian Office, National Alliance of State and Territorial AIDS Directors, Addis Ababa, Ethiopia
| | - Hiwot Tekle Waktola
- Ethiopian Office, National Alliance of State and Territorial AIDS Directors, Addis Ababa, Ethiopia
| | - Behailu Dagne
- Ethiopian Office, National Alliance of State and Territorial AIDS Directors, Addis Ababa, Ethiopia
| | - Rose Hilk
- Department of Epidemiology and Community Health, University of Minnesota, Minneapolis, Minnesota
| | | | - Lucy Slater
- Global Program, National Alliance of State and Territorial AIDS Directors, Washington, District of Columbia
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Whitham HK, Hawes SE, Chu H, Oakes JM, Lifson AR, Kiviat NB, Sow PS, Gottlieb GS, Ba S, Sy MP, Kulasingam SL. A Comparison of the Natural History of HPV Infection and Cervical Abnormalities among HIV-Positive and HIV-Negative Women in Senegal, Africa. Cancer Epidemiol Biomarkers Prev 2017; 26:886-894. [PMID: 28515108 DOI: 10.1158/1055-9965.epi-16-0700] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [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: 08/30/2016] [Revised: 01/05/2017] [Accepted: 01/18/2017] [Indexed: 11/16/2022] Open
Abstract
Background: There is evidence of an interaction between HIV and human papillomavirus (HPV) resulting in increased HPV-associated morbidity and cancer mortality among HIV-positive women. This study aims to determine how the natural history of cervical HPV infection differs by HIV status.Methods: A total of 1,320 women (47% were positive for HIV-1 and/or HIV-2) were followed for an average of two years in Senegal, West Africa between 1994 and 2010. Cytology (with a sub-sample of histology) and HPV DNA testing were performed at approximately 4-month intervals yielding data from over 7,900 clinic visits. Competing risk modeling was used to estimate rates for transitioning between three clinically relevant natural history stages: Normal, HPV, and HSIL (high-grade squamous intraepithelial lesions). Among HIV-positive women, exploratory univariate analyses were conducted examining the impact of HPV type, infection with multiple HPV types, HIV type, CD4+ count, and age.Results: HIV-positive women had higher rates of progression and lower rates of regression compared with HIV-negative women (i.e., adverse transitions). HIV-positive women had a 2.55 [95% confidence interval (CI), 1.69-3.86; P < 0.0001] times higher rate of progression from HPV to HSIL than HIV-negative women (with 24-month absolute risks of 0.18 and 0.07, respectively). Among HIV-positive women, HPV-16/18 infection and CD4+ count <200/mm3 were associated with adverse transitions.Conclusions: Adverse HIV effects persist throughout HPV natural history stages.Impact: In the limited-resource setting of sub-Saharan Africa where cervical cancer screening is not widely available, the high-risk population of HIV-positive women may be ideal for targeted screening. Cancer Epidemiol Biomarkers Prev; 26(6); 886-94. ©2017 AACR.
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Affiliation(s)
- Hilary K Whitham
- Division of Epidemiology and Community Health, University of Minnesota, Minneapolis, Minnesota.
| | - Stephen E Hawes
- Department of Epidemiology, University of Washington, Seattle, Washington
| | - Haitao Chu
- Division of Biostatistics, University of Minnesota, Minneapolis, Minnesota
| | - J Michael Oakes
- Division of Epidemiology and Community Health, University of Minnesota, Minneapolis, Minnesota
| | - Alan R Lifson
- Division of Epidemiology and Community Health, University of Minnesota, Minneapolis, Minnesota
| | - Nancy B Kiviat
- Department of Pathology, University of Washington, Seattle, Washington
| | - Papa Salif Sow
- Service des Maladies Infectieuses, University of Dakar, Dakar, Senegal
| | - Geoffrey S Gottlieb
- Department of Medicine, Division of Allergy and Infectious Diseases/CERID and Department of Global Health, University of Washington, Seattle, Washington
| | - Selly Ba
- Service des Maladies Infectieuses, University of Dakar, Dakar, Senegal
| | - Marie P Sy
- Service des Maladies Infectieuses, University of Dakar, Dakar, Senegal
| | - Shalini L Kulasingam
- Division of Epidemiology and Community Health, University of Minnesota, Minneapolis, Minnesota
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Lifson AR, Grund B, Gardner EM, Kaplan R, Denning E, Engen N, Carey CL, Chen F, Dao S, Florence E, Sanz J, Emery S. Improved quality of life with immediate versus deferred initiation of antiretroviral therapy in early asymptomatic HIV infection. AIDS 2017; 31:953-963. [PMID: 28121710 DOI: 10.1097/qad.0000000000001417] [Citation(s) in RCA: 60] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
OBJECTIVE To determine if immediate compared to deferred initiation of antiretroviral therapy (ART) in healthy persons living with HIV had a more favorable impact on health-related quality of life (QOL), or self-assessed physical, mental, and overall health status. DESIGN QOL was measured in the Strategic Timing of Antiretroviral Therapy study, which randomized healthy ART-naive persons living with HIV with CD4 cell counts above 500 cells/μl from 35 countries to immediate versus deferred ART. METHODS At baseline, months 4 and 12, then annually, participants completed a visual analog scale (VAS) for 'perceived current health' and the Short-Form 12-Item Health Survey version 2 from which the following were computed: general health perception; physical component summary (PCS); and mental component summary (MCS); the VAS and general health were rated from 0 (lowest) to 100 (highest). RESULTS QOL at study entry was high (mean scores: VAS = 80.9, general health = 72.5, PCS = 53.7, MCS = 48.2). Over a mean follow-up of 3 years, changes in all QOL measures favored the immediate group (P < 0.001); estimated differences were as follows: VAS = 1.9, general health = 3.6, PCS = 0.8, MCS = 0.9. When QOL changes were assessed across various demographic and clinical subgroups, treatment differences continued to favor the immediate group. QOL was poorer in those experiencing primary outcomes; however, when excluding those with primary events, results remained favorable for immediate ART recipients. CONCLUSION In an international randomized trial in ART-naive participants with above 500 CD4 cells/μl, there were modest but significant improvements in self-assessed QOL among those initiating ART immediately compared to deferring treatment, supporting patient-perceived health benefits of initiating ART as soon as possible after an HIV diagnosis.
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Lifson AR, Workneh S, Shenie T, Ayana DA, Melaku Z, Bezabih L, Waktola HT, Dagne B, Hilk R, Winters KC, Slater L. Prevalence and factors associated with use of khat: a survey of patients entering HIV treatment programs in Ethiopia. Addict Sci Clin Pract 2017; 12:3. [PMID: 28057079 PMCID: PMC5217655 DOI: 10.1186/s13722-016-0069-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [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: 05/31/2016] [Accepted: 12/23/2016] [Indexed: 11/26/2022] Open
Abstract
Background Khat, a plant native to East Africa, has psychoactive constituents similar to amphetamine. Chronic khat use can lead to psychological dependence with multiple physical and mental health harms, complicating clinical management of people living with HIV. In two Ethiopian cities where khat is common, we evaluated prevalence and correlates of khat use among patients new to HIV care. Methods During 2013–2014, we surveyed 322 patients recently enrolled in HIV clinics in Dire Dawa and Harar about khat use, demographics, smoking and alcohol use, clinical illness, food insecurity, and social support. We analyzed factors associated with khat use in the past year, as well as heaviest use of khat (based on greatest number of hours used in a typical month). Results 242 (75%) respondents reported lifetime khat use; 209 (65%) reported khat use during the previous year. 54% of khat users started before age 19 years. Although 84% believed that using khat every day is dangerous for health if you have HIV, khat was used in the previous year a median of 5 h/days and 30 days/month; 21% said they felt a need to cut down or control their khat use but had difficulty doing so. Those using khat were more likely to report smoking (46%) and alcohol use (49%) compared to non-khat users (1 and 31% respectively). Those reporting heaviest khat use (≥180 h/typical month) were more likely to rate their health status as poor, have an underweight BMI (≤18.5 kg/m2), report more symptoms of chronic illness, and agree with more statements indicating a negative physical quality of life. In multivariate analysis, heavy users were more likely to be male, Muslim, and non-married. Conclusions Khat use was common among HIV patients entering care, and associated with symptoms of poorer physical health. Over half started khat use when they were young. Although most believed khat is harmful for HIV patients, a number of respondents reported some difficulty controlling their drug use. In settings where khat is legal and widely utilized, developing interventions for responsible use represent an important health priority as part of comprehensive care for people living with HIV.
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Affiliation(s)
- Alan R Lifson
- Division of Epidemiology and Community Health, University of Minnesota, 1300 S. Second Street, Suite 300, Minneapolis, MN, 55454-1015, USA.
| | - Sale Workneh
- Ethiopian Office, National Alliance of State and Territorial AIDS Directors, Addis Ababa, Ethiopia
| | - Tibebe Shenie
- Ethiopian Office, National Alliance of State and Territorial AIDS Directors, Addis Ababa, Ethiopia
| | | | - Zenebe Melaku
- International Center for AIDS Care and Treatment Program, Addis Ababa, Ethiopia
| | - Lemlem Bezabih
- Ethiopian Office, National Alliance of State and Territorial AIDS Directors, Addis Ababa, Ethiopia
| | - Hiwot Tekle Waktola
- Ethiopian Office, National Alliance of State and Territorial AIDS Directors, Addis Ababa, Ethiopia
| | - Behailu Dagne
- Ethiopian Office, National Alliance of State and Territorial AIDS Directors, Addis Ababa, Ethiopia
| | - Rose Hilk
- Division of Epidemiology and Community Health, University of Minnesota, 1300 S. Second Street, Suite 300, Minneapolis, MN, 55454-1015, USA
| | | | - Lucy Slater
- Global Program, National Alliance of State and Territorial AIDS Directors, Washington, DC, USA
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Lifson AR, Workneh S, Hailemichael A, Demisse W, Slater L, Shenie T. Implementation of a Peer HIV Community Support Worker Program in Rural Ethiopia to Promote Retention in Care. J Int Assoc Provid AIDS Care 2016; 16:75-80. [PMID: 26518590 DOI: 10.1177/2325957415614648] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [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: 11/16/2022] Open
Abstract
Retention in care is a major challenge for HIV treatment programs, including in rural and in resource-limited settings. To help reduce loss to follow-up (LTFU) for HIV-infected patients new to care in rural Ethiopia, 142 patients were assigned 1 of 13 trained community health support workers (CHSWs) who were HIV positive and from the same neighborhood/village. The CHSWs provided HIV and health education, counseling/social support, and facilitated communication with the HIV clinics. With 7 deaths and 3 transfers, the 12-month retention rate was 94% (95% CI = 89%-97%), and no client was LTFU in the project. Between enrollment and 12 months, clients had significant ( P ≤ .001) improvements in HIV knowledge (17% increase), physical and mental quality of life (81% and 21% increase), internalized stigma (97% decrease), and perceived social support (24% increase). In rural and resource-limited settings, community-based CHSW programs can complement facility-based care in reducing LTFU and improving positive outcomes for HIV-infected people who enter care.
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Affiliation(s)
- Alan R Lifson
- 1 Division of Epidemiology and Community Health, University of Minnesota, Minneapolis, MN, USA
| | - Sale Workneh
- 2 Ethiopian Office, National Alliance of State and Territorial AIDS Directors, Addis Ababa, Ethiopia
| | - Abera Hailemichael
- 2 Ethiopian Office, National Alliance of State and Territorial AIDS Directors, Addis Ababa, Ethiopia
| | - Workneh Demisse
- 2 Ethiopian Office, National Alliance of State and Territorial AIDS Directors, Addis Ababa, Ethiopia
| | - Lucy Slater
- 3 Global Program, National Alliance of State and Territorial AIDS Directors, Washington, DC USA
| | - Tibebe Shenie
- 2 Ethiopian Office, National Alliance of State and Territorial AIDS Directors, Addis Ababa, Ethiopia
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Lifson AR, Workneh S, Hailemichael A, Demissie W, Slater L, Shenie T. Perceived social support among HIV patients newly enrolled in care in rural Ethiopia. AIDS Care 2016; 27:1382-6. [PMID: 26679266 DOI: 10.1080/09540121.2015.1098765] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Social support significantly enhances physical and mental health for persons with human immunodeficiency virus (HIV). We surveyed 142 rural Ethiopian HIV patients newly enrolled in care for perceived social support and factors associated with low support levels. Using the Social Provisions Scale (SPS), the mean summary score was 19.1 (possible scores = 0-48). On six SPS subscales, mean scores (possible scores = 0-8), were: Reliable Alliance (others can be counted on for tangible assistance) = 2.8, Attachment (emotional closeness providing sense of security) = 2.9, Reassurance of Worth (recognition of competence and value by others) = 3.2, Guidance (provision of advice or information by others) = 3.2, Social Integration (belonging to a group with similar interests and concerns) = 3.5, and Nurturance (belief that others rely on one for their well-being) = 3.6. In multivariate analysis, factors significantly associated with lower social support scores were: lower education level (did not complete primary school) (p = .019), lower total score on knowledge items about HIV care/treatment (p = .038), and greater number of external stigma experiences in past three months (p < .001); greater number of chronic disease symptoms was of borderline significance (p = .098). Among rural Ethiopian patients newly entering HIV care, we found moderate and varying levels of perceived social support, with lowest scores for subscales reflecting emotional closeness and reliance on others for tangible assistance. Given that patients who have recently learned their diagnosis and entered care may be an especially vulnerable group, programs to help identify and address social support needs can provide multiple benefits in facilitating the best possible physical, emotional and functional quality of life for people living with HIV.
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Affiliation(s)
- Alan R Lifson
- a Division of Epidemiology and Community Health , University of Minnesota , Minneapolis , MN , USA
| | - Sale Workneh
- b Ethiopian Office, National Alliance of State and Territorial AIDS Directors , Addis Ababa , Ethiopia
| | - Abera Hailemichael
- b Ethiopian Office, National Alliance of State and Territorial AIDS Directors , Addis Ababa , Ethiopia
| | - Workneh Demissie
- b Ethiopian Office, National Alliance of State and Territorial AIDS Directors , Addis Ababa , Ethiopia
| | - Lucy Slater
- c Global Program, National Alliance of State and Territorial AIDS Directors , Washington , DC , USA
| | - Tibebe Shenie
- b Ethiopian Office, National Alliance of State and Territorial AIDS Directors , Addis Ababa , Ethiopia
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Lifson AR, Grandits GA, Gardner EM, Wolff MJ, Pulik P, Williams I, Burman WJ. Quality of life assessment among HIV-positive persons entering the INSIGHT Strategic Timing of AntiRetroviral Treatment (START) trial. HIV Med 2015; 16 Suppl 1:88-96. [PMID: 25711327 DOI: 10.1111/hiv.12237] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [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: 11/21/2014] [Indexed: 12/17/2022]
Abstract
OBJECTIVES With HIV treatment prolonging survival and HIV infection now managed as a chronic illness, quality of life (QOL) is important to evaluate in persons living with HIV (PLWH). We assessed at study entry the QOL of antiretroviral-naïve PLWH with CD4 counts > 500 cells/μL in the Strategic Timing of AntiRetroviral Treatment (START) clinical trial. METHODS QOL was assessed with: (1) a visual analogue scale (VAS) for self-assessment of overall current health; (2) the Short-Form 12-Item Version 2 Health Survey(®) (SF-12V2), for which responses are summarized into eight individual QOL domains plus component summary scores for physical health [the Physical Health Component Summary (PCS)] and mental health [the Mental Health Component Summary (MCS)]. The VAS and eight domain scores were scaled from 0 to 100. Mean QOL measures were calculated overall and by demographic, clinical and behavioural factors. RESULTS A total of 4631 participants completed the VAS and 4119 the SF-12. The mean VAS score (with standard deviation) was 80.9 ± 15.7. Mean SF-12 domain scores were lowest for vitality (66.3 ± 26.4) and mental health (68.6 ± 21.4), and highest for physical functioning (89.3 ± 23.0) and bodily pain (88.0 ± 21.4). Using multiple linear regression, PCS scores were lower (P < 0.001) for Asians, North Americans, female participants, older participants, and those with less education, longer duration of known HIV infection, alcoholism/substance dependence and body mass index ≥ 30 kg/m(2) . MCS scores were highest (P < 0.001) for Africans, South Americans and older participants, and lowest for female participants, current smokers and those with alcoholism/substance dependence. CONCLUSIONS In this primarily healthy population, QOL was mostly favourable, emphasizing that it is important that HIV treatments do not negatively impact QOL. Self-assessed physical health summary scores were higher than mental health scores. Factors such as older age and geographical region had different effects on perceived physical and mental health.
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Affiliation(s)
- A R Lifson
- University of Minnesota, Minneapolis, MN, USA
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12
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O'Connor JL, Gardner EM, Esser S, Mannheimer SB, Lifson AR, Telzak EE, Phillips AN. A simple self-reported adherence tool as a predictor of viral rebound in people with viral suppression on antiretroviral therapy. HIV Med 2015; 17:124-32. [PMID: 26186609 DOI: 10.1111/hiv.12284] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [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: 05/01/2015] [Indexed: 11/30/2022]
Abstract
OBJECTIVES The aim of the study was to investigate the relationship between self-reported antiretroviral therapy (ART) adherence and virological outcomes in the multinational Strategies for Management of Antiretroviral Therapy (SMART) study. METHODS Eligible participants were from the continuous ART arm and had at least one viral load (VL) ≤ 50 HIV-1 RNA copies/mL and a subsequent VL value (VL pair). Self-reported adherence was measured at each visit using a five-point Likert scale which employed a 7-day recall. High adherence was defined as taking 'all pills every day' (level 1) for every regimen component; all others had suboptimal adherence (levels 2 - 5). In individuals with VL suppression (≤ 50 copies/mL), the association between adherence (at the time of VL suppression) and VL rebound (> 200 copies/mL at next visit) was assessed using multivariable logistic regression with generalized estimating equations. RESULTS A total of 10 761 sets of VL pairs from 1986 participants were included in the study. For 1220 (11%) VL pairs, adherence was suboptimal. For 507 VL pairs (5%), VL rebound occurred. The risk of rebound generally increased as adherence decreased: 4.2% for level 1, 7.7% for level 2, 16.3% for level 3, 9.4% for level 4 and 12.9% for level 5. In multivariable analysis, suboptimal adherence at the time of suppression was associated with a 50% increased odds of experiencing subsequent VL rebound [odds ratio (OR) 1.51; 95% confidence interval (CI) 1.19-1.92; P = 0.0023], compared with high adherence. CONCLUSIONS Self-reported suboptimal adherence in people with VL suppression is associated with an increased risk of VL rebound. Our findings highlight the importance of continued adherence counselling, even in people with VL suppression, and to ensure that people with HIV infection maintain excellent adherence in order to minimize the risk of VL rebound.
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Affiliation(s)
- J L O'Connor
- Research Department of Infection and Population Health, University College London, London, UK
| | | | - S Esser
- Department of Dermatology and Venereology, HIV/STD Center, University Hospital Essen, Essen, Germany
| | - S B Mannheimer
- Department of Medicine, Harlem Hospital, Columbia University College of Physicians & Surgeons, New York, NY, USA
| | - A R Lifson
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minnesota, MN, USA
| | - E E Telzak
- Department of Medicine, SBH Health System, Albert Einstein College of Medicine, Bronx, NY, USA
| | - A N Phillips
- Research Department of Infection and Population Health, University College London, London, UK
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Lifson AR, Nelson R, Prineas RJ, Duprez D. Re: "Lessons learned from the design and implementation of myocardial infarction adjudication tailored for HIV clinical cohorts". Am J Epidemiol 2014; 180:449. [PMID: 24989244 DOI: 10.1093/aje/kwu165] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Affiliation(s)
- Alan R Lifson
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, MN 55455
| | - Ray Nelson
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN 55455
| | - Ronald J Prineas
- Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, NC 27157
| | - Daniel Duprez
- Department of Medicine, Medical School, University of Minnesota, Minneapolis, MN 55455
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Lifson AR, Demisse W, Ketema K, Tadesse A, May R, Yakob B, Slater L, Shenie T. Failure to test for HIV in rural Ethiopia: knowledge and belief correlates and implications for universal test and treat strategies. J Int Assoc Provid AIDS Care 2013; 12:306-11. [PMID: 23744773 DOI: 10.1177/2325957413488199] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [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: 11/16/2022] Open
Abstract
Goals of universal "test and treat" will never be fully realized if testing acceptance remains low, including rural areas, where HIV is increasingly recognized. We surveyed 250 randomly selected households from a rural Ethiopian town (Arba Minch) and surrounding villages about HIV testing experience, knowledge, and attitudes. Of the 558 adults, 45% were never HIV tested. Those never tested for HIV were more likely to be (P < .05) ≥45 years, rural villagers, and unaware of the benefits of antiretroviral therapy treatment and that persons with HIV can appear healthy; they were more likely to believe HIV-infected persons would be stigmatized and unsupported by their communities. Of those never tested, 70% were interested in HIV testing if offered. Despite recommendations that all persons be HIV tested, almost half of the adult residents in this rural community were never tested. Programs to increase HIV testing must include measures to address stigma/discrimination and knowledge deficits including benefits of early diagnosis and treatment.
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Affiliation(s)
- Alan R Lifson
- Division of Epidemiology and Community Health, University of Minnesota, Minneapolis, MN, USA
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15
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O'Connor JL, Gardner EM, Mannheimer SB, Lifson AR, Esser S, Telzak EE, Phillips AN. Factors associated with adherence amongst 5295 people receiving antiretroviral therapy as part of an international trial. J Infect Dis 2012. [PMID: 23204161 DOI: 10.1093/infdis/jis731] [Citation(s) in RCA: 66] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND We assessed factors associated with antiretroviral therapy (ART) adherence, including specific ART medications. METHODS The Strategies for Management of Antiretroviral Therapy study was an international antiretroviral therapy (ART) strategy trial that compared intermittent ART, using CD4(+) T-cell count as a guide, to continuous ART. Adherence during the 7 days before each visit was measured using self-report. We defined high adherence as self-report of taking "all" pills for each prescribed ART medication; all other reports were defined as suboptimal adherence. Factors associated with adherence were assessed using logistic regression with generalized estimating equations. RESULTS Participants reported suboptimal adherence at 6016 of 35 695 study visits (17%). Factors independently associated with suboptimal adherence were black race, protease inhibitor-containing regimens, greater pill burden, higher maximum number of doses per day, and smoking. Factors independently associated with higher adherence were older age, higher education, region of residence, episodic treatment, higher latest (at the time of adherence) CD4(+) T-cell count, and being prescribed concomitant drugs (ie, medications for comorbidities). Of specific drugs investigated, atazanavir, atazanavir/ritonavir, fosamprenavir, indinavir, indinavir/ritonavir, and lopinavir/ritonavir were associated with suboptimal adherence, and tenofovir disoproxil fumarate/emtricitabine was associated with higher adherence. CONCLUSIONS In this, the largest analysis of ART adherence to date, some protease inhibitor-containing regimens and regimens with >1 dose per day were associated with suboptimal adherence.
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Affiliation(s)
- Jemma L O'Connor
- Research Department of Infection and Population Health, University College London, UCL Royal Free Campus, Rowland Hill St, London, United Kingdom. jemma.o'
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Lifson AR, Demissie W, Tadesse A, Ketema K, May R, Yakob B, Metekia M, Slater L, Shenie T. Barriers to retention in care as perceived by persons living with HIV in rural Ethiopia: focus group results and recommended strategies. J Int Assoc Provid AIDS Care 2012; 12:32-8. [PMID: 22993233 DOI: 10.1177/1545109712456428] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Inability to retain HIV-infected patients in care undermines the benefits of starting millions in low-income countries on antiretroviral therapy (ART). In a hospital HIV clinic in rural southern Ethiopia, we conducted focus groups of HIV-infected men and women to learn more about experiences with and barriers to attending clinic appointments. Respondents reported multiple barriers, including those that were patient related (eg, misunderstandings about ART, mistaken belief in AIDS cures, and drug/alcohol use), clinic related (eg, negative provider interactions, lack of familiarity with patients' medical situation, and overcrowding), medication related (eg, side effects), social (eg, stigma and discrimination and lack of support), and situational/resource related (eg, distance to clinic, lack of funds, competing domestic/work priorities, and lack of food). Based on the lessons learned from these focus groups, we implemented a community intervention to improve retention, using trained community support workers who provide patient education, counseling, social support, problem-solving assistance, needed referrals, and improved communication/linkage to the patients' HIV clinic.
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Affiliation(s)
- Alan R Lifson
- Division of Epidemiology and Community Health, University of Minnesota, Minneapolis, MN 55454, USA.
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Lifson AR, Demissie W, Tadesse A, Ketema K, May R, Yakob B, Metekia M, Slater L, Shenie T. HIV/AIDS stigma-associated attitudes in a rural Ethiopian community: characteristics, correlation with HIV knowledge and other factors, and implications for community intervention. BMC Int Health Hum Rights 2012; 12:6. [PMID: 22553906 PMCID: PMC3512528 DOI: 10.1186/1472-698x-12-6] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/16/2011] [Accepted: 03/09/2012] [Indexed: 11/10/2022]
Abstract
Background Whether scale-up of HIV prevention and care will reduce negative attitudes and discriminatory practices towards persons living with HIV/AIDS (PLWH) is uncertain. An HIV knowledge and attitude survey was conducted in a rural Ethiopian community where HIV prevention and treatment was being rapidly scaled up. Data were analyzed to identify prevalence of and factors associated with stigma-associated attitudes towards PLWH. Methods We surveyed 561 adults from 250 randomly selected households in the rural town of Arba Minch and surrounding villages about positive or negative attitudes towards PLWH, as well as demographic characteristics, and knowledge about HIV transmission and treatment. Results Eighty percent of respondents agreed with ≥ 1 negative statements indicating blame or shame towards PLWH and 41% agreed with ≥ 1 negative statements associated with distancing themselves from PLWH. However, only 14% expressed negative responses about whether PLWH should receive support from their communities. In multivariate analysis, a greater number of negative attitudes towards PLWH was significantly (p < 0.05) associated with: female gender (Odds Ratio [OR] = 1.51), living in a rural village (vs. town neighborhood) (OR = 3.44), not knowing PLWH can appear healthy (OR = 1.78), lack of knowledge about perinatal transmission (OR = 1.49), lack of knowledge about how HIV is not transmitted (e.g. casual contact) (OR = 2.05), lack of knowledge about HIV treatment (OR = 1.80), and not personally knowing a PLWH (OR = 1.41). Conclusions In a rural Ethiopian setting in which rapid scale-up of HIV treatment occurred, many respondents still characterized HIV as associated with shame or blame, or indicated PLWH would be isolated or discriminated against. HIV stigma can hamper both prevention and treatment programs. We identified multiple issues which, if addressed, can help promote a more positive cycle in which PLWH are appreciated as members of one’s own community who are affirmatively interacted with and supported. Stigma reduction programs should address knowledge gaps such as fears of casual contact contagion, and lack of awareness of medical interventions to help prevent HIV disease, as well as building upon community-based attitudes of the importance of supporting and showing compassion for PLWH.
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Affiliation(s)
- Alan R Lifson
- Division of Epidemiology and Community Health, University of Minnesota, 1300 S, Second Street, Suite 300, Minneapolis, MN 55454-1015, USA.
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Lifson AR, Krantz EM, Grambsch PL, Macalino GE, Crum-Cianflone NF, Ganesan A, Okulicz JF, Eaton A, Powers JH, Eberly LE, Agan BK. Clinical, demographic and laboratory parameters at HAART initiation associated with decreased post-HAART survival in a U.S. military prospective HIV cohort. AIDS Res Ther 2012; 9:4. [PMID: 22339893 PMCID: PMC3320559 DOI: 10.1186/1742-6405-9-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2011] [Accepted: 02/10/2012] [Indexed: 11/24/2022] Open
Abstract
Background Although highly active antiretroviral therapy (HAART) has improved HIV survival, some patients receiving therapy are still dying. This analysis was conducted to identify factors associated with increased risk of post-HAART mortality. Methods We evaluated baseline (prior to HAART initiation) clinical, demographic and laboratory factors (including CD4+ count and HIV RNA level) for associations with subsequent mortality in 1,600 patients who began HAART in a prospective observational cohort of HIV-infected U.S. military personnel. Results Cumulative mortality was 5%, 10% and 18% at 4, 8 and 12 years post-HAART. Mortality was highest (6.23 deaths/100 person-years [PY]) in those with ≤ 50 CD4+ cells/mm3 before HAART initiation, and became progressively lower as CD4+ counts increased (0.70/100 PY with ≥ 500 CD4+ cells/mm3). In multivariate analysis, factors significantly (p < 0.05) associated with post-HAART mortality included: increasing age among those ≥ 40 years (Hazard ratio [HR] = 1.32 per 5 year increase), clinical AIDS events before HAART (HR = 1.93), ≤ 50 CD4+ cells/mm3 (vs. CD4+ ≥ 500, HR = 2.97), greater HIV RNA level (HR = 1.36 per one log10 increase), hepatitis C antibody or chronic hepatitis B (HR = 1.96), and HIV diagnosis before 1996 (HR = 2.44). Baseline CD4+ = 51-200 cells (HR = 1.74, p = 0.06), and hemoglobin < 12 gm/dL for women or < 13.5 for men (HR = 1.36, p = 0.07) were borderline significant. Conclusions Although treatment has improved HIV survival, defining those at greatest risk for death after HAART initiation, including demographic, clinical and laboratory correlates of poorer prognoses, can help identify a subset of patients for whom more intensive monitoring, counseling, and care interventions may improve clinical outcomes and post-HAART survival.
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Spaulding AB, Lifson AR, Iverson ER, Ganesan A, Landrum ML, Weintrob AC, Agan BK, Bavaro MF, O'Connell RJ, Macalino GE. Gonorrhoea or chlamydia in a U.S. military HIV-positive cohort. Sex Transm Infect 2012; 88:266-71. [PMID: 22223813 DOI: 10.1136/sextrans-2011-050173] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [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
OBJECTIVES To investigate the epidemiology and risk factors of gonorrhoea (GC) or chlamydia (CT) coinfection in an HIV-positive US military cohort, focusing on the time after participants' knowledge of HIV diagnosis. METHODS The authors analysed data from 4461 participants enrolled in the U.S. Military Natural History Study cohort for GC or CT infection ≥6 months after their HIV-positive test. RESULTS During a mean follow-up of 7.08 years, 482 (11%) participants acquired a GC or CT infection. Of these, 283 (6%) acquired a GC infection, 278 (6%) acquired a CT infection and 123 (3%) had multiple GC or CT infections during follow-up. Risk of GC or CT infection was significantly greater in those younger, male, African-American and with a history of GC or CT infection. CONCLUSIONS Frequent GC and CT diagnoses observed among members of this HIV-positive cohort indicate substantial ongoing risk behaviours that raise concerns for HIV transmission and underscore the need for continued screening to help identify and treat these sexually transmitted infections in this population.
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Affiliation(s)
- Alicen B Spaulding
- University of Minnesota School of Public Health, 1300 S. Second Street, Suite 300, Minneapolis, MN 55454-1015, USA.
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Mocroft A, Lifson AR, Touloumi G, Neuhaus J, Fox Z, Palfreeman A, Vjecha MJ, Hodder S, De Wit S, Lundgren JD, Phillips AN. Haemoglobin and anaemia in the SMART study. Antivir Ther 2011; 16:329-37. [PMID: 21555815 DOI: 10.3851/imp1746] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
BACKGROUND Data from randomized trials on the development of anaemia after interruption of therapy are not well-described. METHODS A total of 2,248 patients from the SMART study were included. We used Cox proportional hazards models to investigate development of new (≤12 mg/dl for females and ≤14 mg/dl for males) or worsening (≤8 mg/dl if anaemic at randomization) anaemia and Poisson regression analyses to explore the relationship between anaemia and the development of AIDS, death or non-AIDS events. RESULTS Overall, 759 patients developed new or worsening anaemia: 420/1,106 (38.0%) in the drug conservation (DC) arm and 339/1127 (30.1%) in the viral suppression (VS) arm (P<0.0001). At 4 months after randomization, patients in the DC arm had a significantly increased risk of developing new or worsening anaemia (adjusted relative hazard 1.56, 95% CI 1.28-1.89). Currently anaemic patients had an increased incidence of AIDS (adjusted incidence rate ratio [IRR] 2.31, 95% CI 1.34-3.98), death (adjusted IRR 2.19, 95% CI 1.23-3.87) and non-AIDS events (adjusted IRR 2.98, 95% CI 2.01-4.40) compared to non-anaemic patients. CONCLUSIONS Patients who interrupted combination antiretroviral therapy had a higher risk of new or worsening anaemia. Anaemic patients had a higher incidence of AIDS, non-AIDS defining events or deaths, possibly due to deteriorating health and subclinical disease.
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Robien MA, Lifson AR, Duval S, Nichol KL, Ferrieri P. Telephone survey assessment of household patterns of influenza vaccination, Twin Cities seven county metro area, 2008–2009. Vaccine 2011; 29:4033-42. [DOI: 10.1016/j.vaccine.2011.03.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2010] [Revised: 02/09/2011] [Accepted: 03/12/2011] [Indexed: 11/29/2022]
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Lifson AR, Krantz EM, Eberly LE, Dolan MJ, Marconi VC, Weintrob AC, Crum-Cianflone NF, Ganesan A, Grambsch PL, Agan BK. Long-term CD4+ lymphocyte response following HAART initiation in a U.S. Military prospective cohort. AIDS Res Ther 2011; 8:2. [PMID: 21244701 PMCID: PMC3037838 DOI: 10.1186/1742-6405-8-2] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2010] [Accepted: 01/18/2011] [Indexed: 02/04/2023] Open
Abstract
Background Among HIV-infected persons initiating highly active antiretroviral therapy (HAART), early CD4+ lymphocyte count increases are well described. However, whether CD4+ levels continue to increase or plateau after 4-6 years is controversial. Methods To address this question and identify other determinants of CD4+ response, we analyzed data for 1,846 persons from a prospective HIV military cohort study who initiated HAART, who had post-HAART CD4+ measurements, and for whom HIV seroconversion (SC) date was estimated. Results CD4+ count at HAART initiation was ≤ 200 cells/mm3 for 23%, 201-349 for 31%, 350-499 for 27%, and ≥500 for 19%. The first 6 months post-HAART, the greatest CD4+ increases (93-151 cells) occurred, with lesser increases (22-36 cells/year) through the first four years. Although CD4+ changes for the entire cohort were relatively flat thereafter, HIV viral load (VL) suppressors showed continued increases of 12-16 cells/year. In multivariate analysis adjusting for baseline CD4+ and post-HAART time interval, CD4+ responses were poorer in those with: longer time from HIV SC to HAART start, lower pre-HAART CD4+ nadir, higher pre-HAART VL, and clinical AIDS before HAART (P < 0.05). Conclusions Small but positive long-term increases in CD4+ count in virally suppressed patients were observed. CD4+ response to HAART is influenced by multiple factors including duration of preceding HIV infection, and optimized if treatment is started with virally suppressive therapy as early as possible.
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Lifson AR, Belloso WH, Davey RT, Duprez D, Gatell JM, Hoy JF, Krum EA, Nelson R, Pedersen C, Perez G, Price RW, Prineas RJ, Rhame FS, Sampson JH, Worley J, INSIGHT Study Group. Development of diagnostic criteria for serious non-AIDS events in HIV clinical trials. HIV Clin Trials 2010; 11:205-19. [PMID: 20974576 DOI: 10.1310/hct1104-205] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
PURPOSE Serious non-AIDS (SNA) diseases are important causes of morbidity and mortality in the HAART era. We describe development of standard criteria for 12 SNA events for Endpoint Review Committee (ERC) use in START, a multicenter international HIV clinical trial. METHODS SNA definitions were developed based upon the following: (1) criteria from a previous trial (SMART), (2) review of published literature, (3) an iterative consultation and review process with the ERC and other content experts, and (4) evaluation of draft SNA criteria using retrospectively collected reports in another trial (ESPRIT). RESULTS Final criteria are presented for acute myocardial infarction, congestive heart failure, coronary artery disease requiring drug treatment, coronary revascularization, decompensated liver disease, deep vein thrombosis, diabetes mellitus, end-stage renal disease, non-AIDS cancer, peripheral arterial disease, pulmonary embolism, and stroke. Of 563 potential SNA events reported in ESPRIT and reviewed by an ERC, 72% met "confirmed" and 13% "probable" criteria. Twenty-eight percent of cases initially reviewed by the ERC required follow-up discussion (adjudication) before a final decision was reached. CONCLUSION HIV clinical trials that include SNA diseases as clinical outcomes should have standardized SNA definitions to optimize event reporting and validation and should have review by an experienced ERC with opportunities for adjudication.
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Affiliation(s)
- Alan R Lifson
- Division of Epidemiology and Community Health, University of Minnesota, Minneapolis, Minnesota 55454-1015, USA.
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Mocroft A, Lifson AR, Touloumi G, Neuhaus J, Fox Z, Palfreeman A, Vjecha M, Hodder S, De Wit S, Lundgren JD, Phillips AN. Haemoglobin and anaemia in the SMART study. J Int AIDS Soc 2010. [PMCID: PMC3112921 DOI: 10.1186/1758-2652-13-s4-p144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Lifson AR, Neuhaus J, Arribas JR, van den Berg-Wolf M, Labriola AM, Read TRH. Smoking-related health risks among persons with HIV in the Strategies for Management of Antiretroviral Therapy clinical trial. Am J Public Health 2010; 100:1896-903. [PMID: 20724677 DOI: 10.2105/ajph.2009.188664] [Citation(s) in RCA: 217] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVES We sought to determine smoking-related hazard ratios (HRs) and population-attributable risk percentage (PAR%) for serious clinical events and death among HIV-positive persons, whose smoking prevalence is higher than in the general population. METHODS For 5472 HIV-infected persons enrolled from 33 countries in the Strategies for Management of Antiretroviral Therapy clinical trial, we evaluated the relationship between baseline smoking status and development of AIDS-related or serious non-AIDS events and overall mortality. RESULTS Among all participants, 40.5% were current smokers and 24.8% were former smokers. Adjusted HRs were higher for current than for never smokers for overall mortality (2.4; P < .001), major cardiovascular disease (2.0; P = .002), non-AIDS cancer (1.8; P = .008), and bacterial pneumonia (2.3; P < .001). Adjusted HRs also were significantly higher for these outcomes among current than among former smokers. The PAR% for current versus former and never smokers combined was 24.3% for overall mortality, 25.3% for major cardiovascular disease, 30.6% for non-AIDS cancer, and 25.4% for bacterial pneumonia. CONCLUSIONS Smoking contributes to substantial morbidity and mortality in this HIV-infected population. Providers should routinely integrate smoking cessation programs into HIV health care.
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Affiliation(s)
- Alan R Lifson
- Division of Epidemiology and Community Health, University of Minnesota, Minneapolis, MN 55454-1015, USA.
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Chun HM, Fieberg AM, Hullsiek KH, Lifson AR, Crum-Cianflone NF, Weintrob AC, Ganesan A, Barthel RV, Bradley WP, Agan BK, Landrum ML. Epidemiology of Hepatitis B virus infection in a US cohort of HIV-infected individuals during the past 20 years. Clin Infect Dis 2010; 50:426-36. [PMID: 20047484 DOI: 10.1086/649885] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND The epidemiologic trends of hepatitis B virus (HBV) infection in human immunodeficiency virus (HIV)-infected patients over the past 20 years are largely unknown. METHODS Prevalence and risk factors for HBV infection overall, at the time of HIV infection, and after HIV infection were examined in an ongoing observational HIV cohort study. Risk factors for HBV infection at the time of diagnosis of HIV infection were evaluated using logistic regression, and risk of incident HBV infection after diagnosis of HIV infection was evaluated using Cox proportional hazards models. RESULTS Of the 2769 evaluable participants, 1078 (39%) had HBV infection, of whom 117 (11%) had chronic HBV infection. The yearly cross-sectional prevalence of HBV infection decreased from a peak of 49% in 1995 to 36% in 2008 (P < .001). The prevalence of HBV infection at the time of diagnosis of HIV infection decreased during 1989-2008 from 34% to 9% (P < .001). The incidence of HBV infection after diagnosis of HIV infection decreased from 4.0 cases per 100 person-years during the pre-highly active antiretroviral therapy (HAART) era to 1.1 cases per 100 person-years during the HAART era (P < .001); however, this incidence remained unchanged during 2000-2008 (P = .49), with >20% of HBV infections occurring after HIV infection being chronic. Decreased risk of HBV infection after diagnosis of HIV infection was associated with higher CD4 cell count and the use of HBV-active HAART. Receipt of 1 dose of HBV vaccine was not associated with reduced risk of HBV infection after diagnosis of HIV infection. CONCLUSIONS Although the burden of HBV infection overall is slowly decreasing among HIV-infected individuals, the persistent rate of HBV infection after diagnosis of HIV infection raises concern that more-effective prevention strategies may be needed to significantly reduce the prevalence of HBV infection in this patient population.
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Affiliation(s)
- Helen M Chun
- Naval Health Research Center and Naval Medical Center San Diego, San Diego, California, USA
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Lifson AR, Rybicki SL, Hadsall C, Dickinson S, Van Zyl A, Carr P. A training program for nurses and other health professionals in rural-based settings on screening and clinical management of HIV and other sexually transmitted infections. J Assoc Nurses AIDS Care 2009; 20:77-85. [PMID: 19118774 DOI: 10.1016/j.jana.2008.09.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [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: 07/02/2008] [Accepted: 09/25/2008] [Indexed: 11/18/2022]
Abstract
Populations at risk for HIV and other sexually transmitted infections (STIs) include those living in rural areas. The authors describe a statewide training program that targeted rural-based health professionals. This program focused on HIV, STIs, and viral hepatitis and was designed to (a) enhance participants' ability to conduct sexual histories and risk assessments, (b) educate clients about risk reduction and prevention, (c) screen for and diagnose these infections, (d) clinically manage clients with positive screening test results, (e) access prevention and other educational materials, and (f) conduct other clinical and public health activities. A total of 122 participants reflecting a wide variety of practice settings attended training at five sites throughout Minnesota; 74% of participants were nurses and 81% characterized employment settings as rural. Nurses and other health professionals in rural settings are an important training priority and can play an important role in education, prevention, screening, and clinical care for HIV and other STIs.
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Affiliation(s)
- Alan R Lifson
- Division of Epidemiology and Community Health, University of Minnesota, Minneapolis, MN, USA
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Lifson AR, Belloso WH, Carey C, Davey RT, Duprez D, El-Sadr WM, Gatell JM, Gey DC, Hoy JF, Krum EA, Nelson R, Nixon DE, Paton N, Pedersen C, Perez G, Price RW, Prineas RJ, Rhame FS, Sampson J, Worley J. Determination of the underlying cause of death in three multicenter international HIV clinical trials. HIV Clin Trials 2008; 9:177-85. [PMID: 18547904 DOI: 10.1310/hct0903-177] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
PURPOSE Describe processes and challenges for an Endpoint Review Committee (ERC) in determining and adjudicating underlying causes of death in HIV clinical trials. METHOD Three randomized HIV trials (two evaluating interleukin-2 and one treatment interruption) enrolled 11,593 persons from 36 countries during 1999-2008. Three ERC members independently reviewed each death report and supporting source documentation to assign underlying cause of death; differences of opinion were adjudicated. RESULTS Of 453 deaths reported through January 14, 2008, underlying causes were as follows: 10% AIDS-defining diseases, 21% non-AIDS malignancies, 9% cardiac diseases, 9% liver disease, 8% non-AIDS-defining infections, 5% suicides, 5% other traumatic events/accidents, 4% drug overdoses/acute intoxications, 11% other causes, and 18% unknown. Major reasons for unknown classification were inadequate clinical information or supporting documentation to determine cause of death. Half (51%) of deaths reviewed by the ERC required follow-up adjudication; consensus was eventually always reached. CONCLUSION ERCs can successfully provide blinded, independent, and systematic determinations of underlying cause of death in HIV clinical trials. Committees should include those familiar with AIDS and non-AIDS-defining diseases and have processes for adjudicating differences of opinion. Training for local investigators and procedure manuals should emphasize obtaining maximum possible documentation and follow-up information on all trial deaths.
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Affiliation(s)
- Alan R Lifson
- University of Minnesota, Minneapolis, Minnesota 55454-1015, USA.
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Affiliation(s)
- Alan R Lifson
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, MN 55455, USA.
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Lifson AR, Rhame FS, Belloso WH, Dragsted UB, El-Sadr WM, Gatell JM, Hoy JF, Krum EA, Nelson R, Pedersen C, Pett SL, Davey RT. Reporting and evaluation of HIV-related clinical endpoints in two multicenter international clinical trials. HIV Clin Trials 2006; 7:125-41. [PMID: 16880169 DOI: 10.1310/7mer-xfa7-1762-e2wr] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE The processes for reporting and review of progression of HIV disease clinical endpoints are described for two large phase III international clinical trials. METHOD SILCAAT and ESPRIT are multicenter randomized HIV trials evaluating the impact of interleukin-2 on disease progression and death in HIV-infected patients receiving antiretroviral therapy. We report definitions used for HIV progression of disease endpoints, procedures for site reporting of such events, processes for independent review of reported events by an Endpoint Review Committee (ERC), and the procedure for adjudication of differences of opinion between reviewers. RESULTS Of 473 events reported through May 1, 2006, 28% were judged by an ERC to meet "confirmed" criteria and 38% to meet "probable" criteria; 34% were classified "does not meet criteria." For diseases with >5 case reports, the proportion accepted as either "confirmed" or "probable" events was highest for cervical cancer (100%), non-Hodgkin's lymphoma (88%), cryptococcosis (82%), and cryptosporidiosis (80%) and was lowest for HIV encephalopathy (25%), HIV wasting syndrome (33%), and multidermatomal herpes zoster (35%). 25% of cases required adjudication between reviewers before diagnostic certainty was assigned. CONCLUSION Important requirements for HIV trials using clinical endpoints include objective definitions of "confirmed" and "probable," a formal reporting process with adequate information and supporting source documentation, evaluation by independent blinded reviewers, and procedures for adjudication.
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Affiliation(s)
- Alan R Lifson
- Department of Epidemiology and Community Health, University of Minnesota, 1300 South Second Street, Minneapolis, MN 55454, USA.
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Lifson AR, Thai D, Hang K. Lack of immunization documentation in Minnesota refugees: challenges for refugee preventive health care. ACTA ACUST UNITED AC 2006; 3:47-52. [PMID: 16228801 DOI: 10.1023/a:1026662618911] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Children and adults immigrating to the United States without documentation of vaccinations or evidence of immunity should receive age-appropriate immunizations. To learn how often immunization documentation is lacking, we reviewed medical screening records of 1,389 primary refugees over 18 months of age who came Minnesota during 1998. Restricting our analysis to those age groups for whom specific immunizations are recommended, 81.1% of refugees lacked documentation of receiving three doses of diphtheria and tetanus vaccines; 78.8% lacked documentation of one dose of measles vaccine, and 63.8% lacked documentation of three doses of polio vaccine. Of refugees without a known positive test for hepatitis B antigen or antibody, 99.5% lacked documentation of receiving three doses of hepatitis B vaccine. Documentation rates decreased with increasing age, and were lowest for refugees from sub-Saharan Africa (p < 0.001). Refugees and other immigrants may face a number of barriers to receiving necessary immunizations. Health care providers seeing these new arrivals need to ensure that they do fail to receive recommended vaccinations and other preventive health care.
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Affiliation(s)
- A R Lifson
- Acute Disease Prevention Services Section, Minnesota Department of Health, Minneapolis, Minnesota, USA.
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Lifson AR, Rybicki SL, Knust DM, Linsk N. Minnesota's Midwest AIDS Training and Education Center: helping health care providers remain current on a rapidly changing epidemic. Minn Med 2004; 87:44-7. [PMID: 15693263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/01/2023]
Abstract
Since 1990, the number of people in Minnesota living with HIV/AIDS has been steadily increasing. The demographics of who is infected with HIV have changed, with more women and people of color being diagnosed. In addition, with new therapies and continually updated treatment recommendations, the information needed to provide quality medical care to HIV-infected patients is constantly evolving. Thus, providers who care for patients with HIV/AIDS need ongoing education about the disease. The Midwest AIDS Training and Education Center (MATEC) is a federally funded program that helps health care providers stay abreast of HIV clinical care and management knowledge. Based at the University of Illinois at Chicago, MATEC provides services in seven states, including Minnesota. This article describes how MATEC's HIV/AIDS training and education programs are being implemented in Minnesota and the different ways MATEC is delivering provider education in this important area.
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Lifson AR. Do alternate modes for transmission of human immunodeficiency virus exist? - A review. Int J Gynaecol Obstet 2004. [DOI: 10.1016/0020-7292(88)90152-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Lifson AR, Thai D, O'Fallon A, Mills WA, Hang K. Prevalence of tuberculosis, hepatitis B virus, and intestinal parasitic infections among refugees to Minnesota. Public Health Rep 2002; 117:69-77. [PMID: 12297684 PMCID: PMC1497409 DOI: 10.1093/phr/117.1.69] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
OBJECTIVE The purpose of this study was to define the prevalence of infection with Mycobacterium tuberculosis, hepatitis B virus, and various intestinal parasites among different groups of primary refugees immigrating to Minnesota. METHODS 2,545 refugees arriving in Minnesota during 1999 received a domestic health examination that included tuberculin skin testing, hepatitis B virus serologic testing, and stool ova and parasite examinations. The Refugee Health Assessment form asked specifically about screening results for amebiasis, ascariasis, clonorchiasis, giardiasis, hookworm, schistosomiasis, strongyloidiasis, and trichuriasis. RESULTS Forty-nine percent of refugees had a reactive tuberculin test of >or=10 mm induration, with a higher prevalence in males (54%) and refugees >or=18 years of age (63%) (p<0.001). Seven percent had a positive hepatitis B surface antigen, with the highest prevalence in those people from sub-Saharan Africa (8%) (p=0.002) and those refugees >or=18 years of age (9%) (p=0.006). Twenty-two percent had one or more intestinal parasites asked about, including 30% of those refugees <18 years of age (p<0.001). The most commonly reported parasitic infections were trichuriasis (8%) and giardiasis (7%). CONCLUSIONS Evidence of infection with M. tuberculosis, hepatitis B virus, or one of eight intestinal parasites was present in a substantial proportion of refugees receiving the domestic health assessment. Screening for such infections gives new immigrants the opportunity to receive important medical evaluation and treatment, provides valuable surveillance data, and allows appropriate public health measures to be taken.
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Halcón LL, Lifson AR, Shew M, Joseph M, Hannan PJ, Hayman CR. Pap test results among low-income youth: prevalence of dysplasia and practice implications. J Obstet Gynecol Neonatal Nurs 2002; 31:294-304. [PMID: 12033542 DOI: 10.1111/j.1552-6909.2002.tb00051.x] [Citation(s) in RCA: 4] [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] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVES To describe Papanicolaou (Pap) test findings and identify prevalence and correlates of dysplastic cervical abnormalities in low-income adolescent females. DESIGN AND SETTING This cross-sectional study included a modified random sample of female students ages 16 to 25 years at 54 U.S. Job Corps centers. PARTICIPANTS 5,734 female students enrolled in a federal job training program. Admission health records were reviewed and abstracted. MAIN OUTCOME MEASURE Pap test findings using the Bethesda classifications. Pap smear results indicating dysplasia (atypical squamous cells of undetermined significance [ASCUS] with dysplasia) or squamous intraepithelial lesions (low-grade squamous interepithelial lesions [LGSIL] or high-grade squamous intraepithelial lesions [HGSIL]). Participants with less severe findings were compared with those who needed follow-up. RESULTS For 71.4% of participants, no abnormalities were found. 15.6% had benign cellular changes, 9.2% had reactive changes, and 9.9% had epithelial cell abnormalities. Of those tested, 5.6% (+/- 0.8%) had dysplastic Pap smear findings, with 0.3% (n = 12) HGSIL. All groups were equally affected, with abnormalities not associated with race/ethnicity, age, geographic region, education level, size of city of residence, or receiving public assistance. CONCLUSIONS In this population, dysplastic Pap smear results were not uncommon. Findings indicate that Pap screening, alone or in combination with more sensitive tests, can identify cervical abnormalities, including HGSIL, that suggest a need for further evaluation or follow-up.
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Affiliation(s)
- Linda L Halcón
- School of Nursing, University of Minnesota, Minneapolis 55454, USA.
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Affiliation(s)
- Alan R Lifson
- Division of Infectious Diseases, Department of Medicine, University of Minnesota, Minneapolis, MN, 55455, USA.
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Abstract
Homeless and runaway youth face a variety of health risks, including those related to substance abuse and use of unsterile needles. During 1998-1999, we recruited 201 Minneapolis homeless youths aged 15-22 years; these youths were interviewed by experienced street outreach workers from settings where street youth were known to congregate. Respondents spent a median of 6 months in the previous year living on the streets or "couch hopping." There were 37% who reported having 15 or more alcoholic drinks per week, 41% smoked 1 pack or more of cigarettes per day, and 37% used marijuana 3 or more times a week; 15% reported lifetime injection drug use, including 6% who used injection drugs within the previous month. Twenty percent had received a tattoo, and 18% body piercing with a needle that had not been sterilized or had been used by someone else. There were 68% who had been tested for human immunodeficiency virus (HIV), 52% for hepatitis B, and 25% for hepatitis C. There were 44% who said they did not have enough information about hepatitis B and C. Less than half (43%) received hepatitis B vaccine; however, 51% of unvaccinated youths indicated that they would receive vaccination if offered. These Midwestern homeless youths face multiple health risks, including those related to substance use and exposure to unsterile needles. Despite unsafe behaviors, many of these youths were interested in methods to protect their health, including education, knowing their HIV or viral hepatitis serostatus, and obtaining hepatitis B immunization.
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Affiliation(s)
- A R Lifson
- The Department of Medicine, University of Minnesota, Minneapolis 55455, USA.
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Lifson AR, Halcón LL, Hannan P, St Louis ME, Hayman CR. Screening for sexually transmitted infections among economically disadvantaged youth in a national job training program. J Adolesc Health 2001; 28:190-6. [PMID: 11226841 DOI: 10.1016/s1054-139x(00)00165-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
PURPOSE To evaluate results of screening for syphilis, gonorrhea, and chlamydia among youth in a federally funded job training program. METHODS Data were evaluated from medical records of 12,881 randomly selected students in 54 U.S. job training centers during 1996. The intake medical evaluation includes serologic testing for syphilis. The policy was for females to receive a pelvic examination with gonorrhea and chlamydia testing and for males to be first screened with a urine leukocyte esterase (LE) assay, with follow-up gonorrhea and chlamydia testing for those with positive LE results. RESULTS Adjusting for our sampling strategy, among females, an estimated 9.2% had a positive chlamydia test, 2.7% a positive gonorrhea test, and 0.4% had a positive syphilis test. Gonorrhea and chlamydia rates among females were highest in African-American followed by Native American students. Chlamydia infection was most common in younger women < or = 17 years of age. An estimated 0.1% of males had a positive syphilis test, and 4.8% of males a positive urine LE test. Of 103 LE-positive males tested for gonorrhea and chlamydia, only 27 (26%) had a positive test for one of these STDs. CONCLUSIONS Our study supports routine screening of adolescents for gonorrhea and chlamydia, including those youth from socioeconomically disadvantaged backgrounds. Because individuals from such backgrounds may not regularly interact with traditional clinical health care systems, screening and treatment should be offered in alternative settings, such as the job training program described in this study.
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Affiliation(s)
- A R Lifson
- Division of Epidemiology, School of Public Health, University of Minnesota, Minneapolis 55455, USA.
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Sellman JS, Lifson AR. AIDS in Africa. A global responsibility. Minn Med 2001; 84:22-6. [PMID: 11242971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/19/2023]
Abstract
The global response to the AIDS epidemic has often been marked by ignorance, fear, shame, and complacency, resulting in a spiraling epidemic in Africa and elsewhere. However, when leaders have confronted the realities of HIV with candor and empathized with those stricken with AIDS, the results are encouraging. Because infectious diseases and their consequences do not respect political borders, HIV presents many challenges for both developing and industrialized nations. AIDS in Africa represents a global challenge and requires sustained political and monetary investments. In 1998, only $300 million in international assistance funds were available for combating HIV/AIDS. However, an estimated $1.6 billion to $2.6 billion annually may be needed to mount an effective response in sub-Saharan Africa alone. Those dollars equal less than $3.50 per person in this region, or less than a bottle of cold medicine one of us might purchase at a U.S. pharmacy. Failure to act aggressively now will cost the world economically and socially, and will result in the loss of millions of lives.
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Affiliation(s)
- J S Sellman
- Division of Infectious Diseases, University of Minnesota Medical School, USA
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Affiliation(s)
- A R Lifson
- Department of Medicine, University of Minnesota, Minneapolis 55455, USA
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Lifson AR, Roddy M, Ehresmann KR. The association of poverty and low immunization rates in ZIP code areas. A retrospective survey of Minnesota kindergartners. Minn Med 2000; 83:51-5. [PMID: 10974917] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
Abstract
This study evaluated indicators of poverty in Minnesota ZIP code areas with low childhood immunization rates. During 1996-1997, a retrospective survey of 68,639 Minnesota kindergarten children was conducted; 68% received four doses of diphtheria, tetanus, and pertussis vaccine, three doses of polio vaccine, and one dose of measles, mumps, and rubella vaccine (4:3:1) by 24 months of age. Of 447 ZIP codes further evaluated, 24 (5%; 13 urban and 11 rural) had 4:3:1 immunization rates at 24 months of < or = 50%. None of 159 ZIP codes in which < 5% of residents were below the poverty line had immunization rates < or = 50%, compared with 9 (32%) of 28 ZIP codes with > or = 15% of residents below the poverty line (p < 0.001). Immunization rates were lowest in ZIP codes with a lower median family income and greater proportion of residents below the poverty line. Surveys such as this can help immunization programs target and monitor prevention activities for these pockets of need.
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Affiliation(s)
- A R Lifson
- Acute Disease Prevention Services Section, Minnesota Department of Health, USA
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Lorvick J, Thompson S, Edlin BR, Kral AH, Lifson AR, Watters JK. Incentives and accessibility: a pilot study to promote adherence to TB prophylaxis in a high-risk community. J Urban Health 1999; 76:461-7. [PMID: 10609595 PMCID: PMC3456694 DOI: 10.1007/bf02351503] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
SETTING A community-based directly observed preventive therapy (DOPT) program for treatment of latent tuberculosis infection among injection drug users (IDUs) in an inner-city neighborhood. OBJECTIVE To test adherence to a 6-month course of DOPT using cash incentives and an easily accessible neighborhood location. DESIGN Street-recruited IDUs (N = 205) were screened for Mycobacterium tuberculosis (TB) infection using the Mantoux test and two controls. Subjects who had a purified protein derivative (PPD) reaction of > or =5 mm, were anergic, or had a history of a positive PPD received clinical evaluation at a community field site, provided in collaboration with the San Francisco Department of Public Health Tuberculosis Clinic. Twenty-eight subjects were considered appropriate candidates for prophylaxis with isoniazid, and 27 enrolled in the pilot study. Participants received twice-weekly DOPT at a community satellite office, with a $10 cash incentive at each visit. RESULTS The 6-month (26-week) regimen was completed by 24/27 (89%) participants. The median time to treatment completion was 27 weeks (range 26 to 34 weeks). The median proportion of dosing days attended in 6 months was 96%. CONCLUSION Community-based DOPT using cash incentives resulted in high levels of adherence and treatment completion among drug users.
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Affiliation(s)
- J Lorvick
- Urban Health Study, University of California, San Francisco 94143-1304, USA.
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Lifson AR, Aitchison-Olson R, Ramesh A. New threats from an old enemy. A physician update on pneumococcus. Minn Med 1999; 82:29-31. [PMID: 10589211] [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] [Subscribe] [Scholar Register] [Indexed: 02/14/2023]
Abstract
Pneumonia and influenza together are the sixth-leading cause of death in this country. Physicians have the tools and influence to prevent many of these deaths and significantly improve their patients' health and quality of life. There is no reason for these tools to be underused.
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Affiliation(s)
- A R Lifson
- Acute Disease Prevention Services Section, Minnesota Department of Health, USA
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Lifson AR, Halcón LL, Johnston AM, Hayman CR, Hannan P, Miller CA, Valway SE. Tuberculin skin testing among economically disadvantaged youth in a federally funded job training program. Am J Epidemiol 1999; 149:671-9. [PMID: 10192315 DOI: 10.1093/oxfordjournals.aje.a009868] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [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: 11/13/2022] Open
Abstract
Low income, medically underserved communities are at increased risk for tuberculosis. Limited population-based national data are available about tuberculous infection in young people from such backgrounds. To determine the prevalence of a positive tuberculin skin test among economically disadvantaged youth in a federally funded job training program during 1995 and 1996, the authors evaluated data from medical records of 22,565 randomly selected students from over 100 job training centers throughout the United States. An estimated 5.6% of students had a documented positive skin test or history of active tuberculosis. Rates were highest among those who were racial/ethnic minorities, foreign born, and (among foreign-born students) older in age (p < 0.001). Weighted rates (adjusting for sampling) were 1.3% for white, 2.2% for Native American, 4.0% for black, 9.6% for Hispanic, and 40.7% for Asian/Pacific Islander students; rates were 2.4% for US-born and 32.7% for foreign-born students. Differences by geographic region of residence were not significant after adjusting for other demographic factors. Tuberculin screening of socioeconomically disadvantaged youth such as evaluated in this study provides important sentinel surveillance data concerning groups at risk for tuberculous infection and allows recommended public health interventions to be offered.
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Affiliation(s)
- A R Lifson
- Division of Epidemiology, School of Public Health, University of Minnesota, Minneapolis 55454, USA
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Lifson AR, Thompson S, Grant S, Hilk R, Lorvick J. Skin Test Anergy among Injection Drug Users Recruited from Community Settings. Journal of Drug Issues 1998. [DOI: 10.1177/002204269802800404] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Five hundred ninety-two drug users (IDUs) from community settings in San Francisco and Oakland, California, were screened for tuberculosis using the tuberculin skin test, as well as for skin test anergy using two controls: mumps antigen and either tetanus toxoid or Candida. Those nonresponsive to one skin test were more likely to be nonresponsive to another, even after stratifying by HIV status. Skin test anergy (defined as nonresponse to the tuberculin skin test and to both controls) occurred in 37% of HIV-positive and 11% of HIV-negative IDUs (p<0.001). Among HIV-negative IDUs, anergy was associated with city of residence (p<0.001), use of cocaine by any route in the last 30 days (p=0.026) and use of speedballs (heroin and cocaine) by any route in the last 30 days (p=0.053). Skin test anergy in this population of IDUs may reflect more generalized defects in the delayed hypersensitivity response. Other exposures besides HIV which occur in IDUs may result in impaired cellular immunity.
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Lifson AR. Training infectious disease epidemiologists for the next millennium. The epidemiology program at the University of Minnesota. Minn Med 1998; 81:53-4. [PMID: 9637861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- A R Lifson
- Division of Epidemiology, School of Public Health, University of Minnesota, USA
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