Alcohol and drug use severity are independently associated with antiretroviral adherence in the current treatment era

Substance use in people with HIV (PWH) negatively impacts antiretroviral therapy (ART) adherence. However, less is known about this in the current treatment era and the impact of specific substances or severity of substance use. We examined the associations of alcohol, marijuana, and illicit drug use (methamphetamine/crystal, cocaine/crack, illicit opioids/heroin) and their severity of use with adherence using multivariable linear regression in adult PWH in care between 2016 and 2020 at 8 sites across the US. PWH completed assessments of alcohol use severity (AUDIT-C), drug use severity (modified ASSIST), and ART adherence (visual analogue scale). Among 9400 PWH, 16% reported current hazardous alcohol use, 31% current marijuana use, and 15% current use of ≥1 illicit drugs. In multivariable analysis, current methamphetamine/crystal use, particularly common among men who had sex with men, was associated with 10.1% lower mean ART adherence (p < 0.001) and 2.6% lower adherence per 5-point higher severity of use (ASSIST score) (p < 0.001). Current and more severe use of alcohol, marijuana, and other illicit drugs were also associated with lower adherence in a dose-dependent manner. In the current HIV treatment era, individualized substance use treatment, especially for methamphetamine/crystal, and ART adherence should be prioritized.

Associations between drug and alcohol use, smoking, and frailty among people with HIV across the United States in the current era of antiretroviral treatment

OBJECTIVE

To examine associations between frailty and drug, alcohol, and tobacco use among a large diverse cohort of people with HIV (PWH) in clinical care in the current era.

METHODS

PWH at 7 sites across the United States completed clinical assessments of patient-reported measures and outcomes between 2016 and 2019 as part of routine care including drug and alcohol use, smoking, and other domains. Frailty was assessed using 4 of the 5 components of the Fried frailty phenotype and PWH were categorized as not frail, pre-frail, or frail. Associations of substance use with frailty were assessed with multivariate Poisson regression.

RESULTS

Among 9336 PWH, 43% were not frail, 44% were prefrail, and 13% were frail. Frailty was more prevalent among women, older PWH, and those reporting current use of drugs or cigarettes. Current methamphetamine use (1.26: 95% CI 1.07-1.48), current (1.65: 95% CI 1.39-1.97) and former (1.21:95% CI 1.06-1.36) illicit opioid use, and former cocaine/crack use (1.17: 95% CI 1.01-1.35) were associated with greater risk of being frail in adjusted analyses. Current smoking was associated with a 61% higher risk of being frail vs. not frail (1.61: 95% CI 1.41-1.85) in adjusted analyses.

CONCLUSIONS

We found a high prevalence of prefrailty and frailty among a nationally distributed cohort of PWH in care. This study identified distinct risk factors that may be associated with frailty among PWH, many of which, such as cigarette smoking and drug use, are potentially modifiable.

Using computer-assisted content analysis to advance anal dysplasia natural history research

OBJECTIVE

Our study aim was to validate the use of computer-aided narrative content analysis in the extraction of standard diagnostic categories using an archived cytology database that included individually overread reference classification.

DESIGN

A retrospective analysis of narrative anal cytology results collected on HIV-infected patients at the University of California, San Diego between January and December 2001.

METHODS

We used computer-assisted content analysis extraction methodology using Wordstat 8.0 (Provalis Research) that operated using a classification dictionary that we developed for the following diagnostic categories: NAMC, ASCUS, LSIL, HSIL. We compared its accuracy to a physician overread manually extracted method: that classified each report into the most severe diagnostic category referenced in the narrative report. Agreement between content analysis mapped diagnostic categories and the reference category was evaluated using kappa agreement.

RESULTS

During 2001, 901 patients underwent 997 anal cytological examinations as routine screening. By reference diagnostic category: 54 (5.4%) were unsatisfactory, 460 (46.1%) were NAMC, 291 (29.2%) were ASCUS, 131 (13.1%) were LSIL, and 61 (6.1%) were HSIL. Computer-aided content analysis extracted a single diagnosis from each report in 963 (96.2%) cases and two diagnoses in 38 (3.8%) cases. The Kappa agreement was 0.96 (0.019 s.e.). There were 29 cases classified ASCUS by reference category but LSIL by adjudicated content analysis. A focused review indicated that the over reader assigned reference category was in error.

CONCLUSION

Computer-aided narrative content analysis of anal cytology results yielded accurate and time-efficient classification into meaningful diagnostic categories that can be used to evaluate screening programs and modeling natural history.

Racial and ethnic disparities in COVID-19 disease incidence independent of comorbidities, among people with HIV in the US

OBJECTIVES

To define the incidence of clinically-detected COVID-19 in people with HIV (PWH) in the US and evaluate how racial and ethnic disparities, comorbidities, and HIV-related factors contribute to risk of COVID-19.

DESIGN

Observational study within the CFAR Network of Integrated Clinical Systems cohort in 7 cities during 2020.

METHODS

We calculated cumulative incidence rates of COVID-19 diagnosis among PWH in routine care by key characteristics including race/ethnicity, current and lowest CD4 count, and geographic area. We evaluated risk factors for COVID-19 among PWH using relative risk regression models adjusted with disease risk scores.

RESULTS

Among 16,056 PWH in care, of whom 44.5% were Black, 12.5% were Hispanic, with a median age of 52 years (IQR 40-59), 18% had a current CD4 count < 350, including 7% < 200; 95.5% were on antiretroviral therapy, and 85.6% were virologically suppressed. Overall in 2020, 649 PWH were diagnosed with COVID-19 for a rate of 4.94 cases per 100 person-years. The cumulative incidence of COVID-19 was 2.4-fold and 1.7-fold higher in Hispanic and Black PWH respectively, than non-Hispanic White PWH. In adjusted analyses, factors associated with COVID-19 included female sex, Hispanic or Black identity, lowest historical CD4 count <350 (proxy for CD4 nadir), current low CD4/CD8 ratio, diabetes, and obesity.

CONCLUSIONS

Our results suggest that the presence of structural racial inequities above and beyond medical comorbidities increased the risk of COVID-19 among PWHPWH with immune exhaustion as evidenced by lowest historical CD4 or current low CD4:CD8 ratio had greater risk of COVID-19.

Correlates of psychological intimate partner violence with HIV care outcomes on patients in HIV care

Background

Among people living with HIV (PLWH), physical intimate partner violence (IPV) is associated with poor virologic, psychiatric, and behavioral outcomes. We examined non-physical, psychological intimate partner violence (psy-IPV) and HIV care outcomes using data from two U.S. consortia.

Methods

We conducted multivariable analyses with robust standard errors to compare patients indicating/not indicating psy-IPV.

Results

Among PLWH (n = 5950), 9.5% indicated psy-IPV; these individuals were younger (− 3; 95% CI [− 2,-4], p-value < 0.001), less likely to be on antiretroviral treatment (ART) (0.73 [0.55,0.97], p = 0.03), less adherent to ART (− 4.2 [− 5.9,-2.4], p < 0.001), had higher odds of detectable viral load (1.43 [1.15,1.78], p = 0.001) and depression (2.63 [2.18,3.18], p < 0.001), and greater use of methamphetamines/crystal [2.98 (2.30,3.87),p < 0.001], cocaine/crack [1.57 (1.24,1.99),p < 0.001], illicit opioids [1.56 (1.13,2.16),p = 0.007], and marijuana [1.40 (1.15,1.70), p < 0.001].

Conclusion

Psychological IPV, even in the absence of physical or sexual IPV, appears to be associated with HIV care outcomes and should be included in IPV measures integrated into routine HIV care.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-11854-x.

Substance use and HIV stage at entry into care among people with HIV

BACKGROUND

Information regarding the impact of substance use on the timing of entry into HIV care is lacking. Better understanding of this relationship can help guide approaches and policies to improve HIV testing and linkage.

METHODS

We examined the effect of specific substances on stage of HIV disease at entry into care in over 5000 persons with HIV (PWH) newly enrolling in care. Substance use was obtained from the AUDIT-C and ASSIST instruments. We examined the association between early entry into care and substance use (high-risk alcohol, methamphetamine, cocaine/crack, illicit opioids, marijuana) using logistic and relative risk regression models adjusting for demographic factors, mental health symptoms and diagnoses, and clinical site.

RESULTS

We found that current methamphetamine use, past and current cocaine and marijuana use was associated with earlier entry into care compared with individuals who reported no use of these substances.

CONCLUSION

Early entry into care among those with substance use suggests that HIV testing may be differentially offered to people with known HIV risk factors, and that individuals with substances use disorders may be more likely to be tested and linked to care due to increased interactions with the healthcare system.

Impact and correlates of sub-optimal social support among patients in HIV care

Social support (SS) predicts health outcomes among patients living with HIV. We administered a brief, validated measure of SS, the Multifactoral Assessment of Perceived Social Support, within a patient-reported outcomes assessment of health domains in HIV care at 4 U.S. clinics in English and Spanish (n = 708). In univariate analysis, low SS was associated with poorer engagement in care, antiretroviral adherence, and health-related quality of life; current methamphetamine/crystal use, depression, anxiety, and HIV stigma (all p < 0.001); any use of either methamphetamines/crystal, illicit opioids, or cocaine/crack (p = 0.001), current marijuana use (p = 0.012), nicotine use (p = 0.005), and concern for sexually transmitted infection exposure (p = 0.001). High SS was associated with undetectable viral load (p = 0.031). Multivariate analyses found low SS independently associated with depression (risk ratio (RR) 3.72, 95% CI 2.93-4.72), lower adherence (RR 0.76, 95% CI 0.64-0.89), poor engagement in care (RR 2.05, 95% CI 1.44-2.96), and having more symptoms (RR 2.29, 95% CI 1.92-2.75). Medium SS was independently associated with depression (RR 2.59, 95% CI 2.00-3.36), poor engagement in care (RR 1.62, 95% CI 1.15-2.29) and having more symptoms (RR 1.75, 95% CI 1.44-2.13). SS assessment may help identify patients at risk for these outcomes.

Characterizing the Human Immunodeficiency Virus Care Continuum Among Transgender Women and Cisgender Women and Men in Clinical Care: A Retrospective Time-series Analysis

BACKGROUND

Prior studies suggest that transgender women (TW) with human immunodeficiency virus (HIV) are less likely to be virally suppressed than cisgender women (CW) and cisgender men (CM). However, prior data are limited by small sample sizes and cross-sectional designs. We sought to characterize the HIV care continuum comparing TW to CW and CM in the United States and Canada.

METHODS

We analyzed annual HIV care continuum outcomes by gender status from January 2001 through December 2015 among adults (aged ≥18 years) in 15 clinical cohorts. Outcomes were retention in care and viral suppression.

RESULTS

The study population included TW (n = 396), CW (n = 14 094), and CM (n = 101 667). TW had lower proportions retained in care than CW and CM (P < .01). Estimates of retention in care were consistently lower in TW, with little change over time within each group. TW and CW had similar proportions virally suppressed over time (TW, 36% in 2001 and 80% in 2015; CW, 35% in 2001 and 83% in 2015) and were lower than CM (41% in 2001 and 87% in 2015). These differences did not reach statistical significance after adjusting for age, race, HIV risk group, and cohort.

CONCLUSIONS

TW experience challenges with retention in HIV care. However, TW who are engaged in care achieve viral suppression that is comparable to that of CW and CM of similar age, race, and HIV risk group. Further research is needed to understand care engagement disparities.

Patient acceptability and usability of a self-administered electronic patient-reported outcome assessment in HIV care: relationship with health behaviors and outcomes

We assessed acceptability/usability of tablet-based patient-reported outcome (PRO) assessments among patients in HIV care, and relationships with health outcomes using a modified Acceptability E-Scale (AES) within a self-administered PRO assessment. Using multivariable linear regression, we measured associations between patient characteristics and continuous combined AES score. Among 786 patients (median age=48; 91% male; 49% white; 17% Spanish-speaking) overall mean score was 26/30 points (SD: 4.4). Mean scores per dimension (max 5, 1=lowest acceptability, 5=highest): ease of use 4.7, understandability 4.7, time burden 4.3, overall satisfaction 4.3, helpfulness describing symptoms/behaviors 4.2, and enjoyability 3.8. Higher overall score was associated with race/ethnicity (+1.3 points/African-American patients (95%CI:0.3-2.3); +1.6 points/Latino patients (95%CI:0.9-2.3) compared to white patients). Patients completing PROs in Spanish scored +2.4 points on average (95%CI:1.6-3.3). Higher acceptability was associated with better quality of life (0.3 points (95%CI:0.2-0.5)) and adherence (0.4 points (95%CI:0.2-0.6)). Lower acceptability was associated with: higher depression symptoms (-0.9 points (95%CI:-1.4 to -0.4)); recent illicit opioid use (-2.0 points (95%CI:-3.9 to -0.2)); multiple recent sex partners (-0.8 points (95%CI:-1.5 to -0.1)). While patients endorsing depression symptoms, recent opioid use, condomless sex, or multiple sex partners found PROs less acceptable, overall, patients found the assessments highly acceptable and easy to use.

Anemia risk factors among people living with HIV across the United States in the current treatment era: a clinical cohort study

Background

Anemia is common among people living with HIV infection (PLWH) and is associated with adverse health outcomes. Information on risk factors for anemia incidence in the current antiretroviral therapy (ART) era is lacking.

Methods

Within a prospective clinical cohort of adult PLWH receiving care at eight sites across the United States between 1/2010–3/2018, Cox proportional hazards regression analyses were conducted among a) PLWH free of anemia at baseline and b) PLWH free of severe anemia at baseline to determine associations between time-updated patient characteristics and development of anemia (hemoglobin < 10 g/dL), or severe anemia (hemoglobin < 7.5 g/dL). Linear mixed effects models were used to examine relationships between patient characteristics and hemoglobin levels during follow-up. Hemoglobin levels were ascertained using laboratory data from routine clinical care. Potential risk factors included: age, sex, race/ethnicity, body mass index, smoking status, hazardous alcohol use, illicit drug use, hepatitis C virus (HCV) coinfection, estimated glomerular filtration rate (eGFR), CD4 cell count, viral load, ART use and time in care at CNICS site.

Results

This retrospective cohort study included 15,126 PLWH. During a median follow-up of 6.6 (interquartile range [IQR] 4.3–7.6) years, 1086 participants developed anemia and 465 participants developed severe anemia. Factors that were associated with incident anemia included: older age, female sex, black race, HCV coinfection, lower CD4 cell counts, VL ≥400 copies/ml and lower eGFR.

Conclusion

Because anemia is a treatable condition associated with increased morbidity and mortality among PLWH, hemoglobin levels should be monitored routinely, especially among PLWH who have one or more risk factors for anemia.

Abstract WMP55: HIV Viral Load and Stroke Risk

Background: Among people living with HIV (PLWH), elevated plasma HIV RNA (viral load, [VL]), indicative of increased inflammation, may be associated with greater risk of stroke.

Methods: Among adult PLWH receiving clinical care at six Centers for AIDS Research Network of Integrated Clinical Systems (CNICS) sites across the U.S. from January 2006 through January 2015, first ischemic or hemorrhagic stroke was identified from adjudicated clinical events. We considered baseline and time-updated VL. Baseline viral load was defined as the most recent viral load before 2006 or at CNICS cohort entry (if after 2006). Cox proportional hazards models were used to assess the relationship between baseline VL and time-updated VL and stroke. We estimated hazard ratios for risk of stroke (all stroke, and ischemic and hemorrhagic stroke separately) comparing the 75 th percentile of VL (“high VL”) to the 25 th percentile (“low VL”). All models were adjusted for age, sex, race/ethnicity, CNICS site, diabetes, treated hypertension, statin use, smoking, nadir CD4, BMI, hepatitis C virus coinfection, and baseline ART use. The hemorrhagic stroke model was also adjusted for FIB-4.

Results: Among 16,648 PLWH over an average follow-up of 4.7 years, there were 146 total strokes (119 ischemic; 19 hemorrhagic). At baseline, the median VL was 41 copies/mL (IQR: 24, 3860). Individuals with high baseline VL were 1.57 times more likely to have a stroke than individuals with low baseline VL (95% CI: 1.22, 2.04). In addition, high baseline VL was associated with increased risk of ischemic stroke (HR: 1.48; 95% CI: 1.11, 1.97) and hemorrhagic stroke (HR: 2.5; 95% CI: 1.25, 4.98). The HR for all strokes comparing high VL and low VL individuals using time-updated VL was 1.84 (95% CI: 1.42-2.40).

Conclusion: Our findings suggest that higher VL is associated with stroke risk after adjusting for traditional stroke risk factors, and may have a greater impact on incidence of hemorrhagic stroke. In addition to reducing HIV-related morbidity and mortality, improving HIV care may also reduce stroke risk.

HCV Screening and Treatment Uptake Among Patients in HIV Care During 2014-2015

BACKGROUND

Despite the high prevalence of hepatitis C virus (HCV) among persons living with HIV (PWH), the prevalence of HCV screening, treatment, and sustained virologic response (SVR) is unknown. This study aims to characterize the continuum of HCV screening and treatment among PWH in HIV care.

SETTING

Adult patients enrolled at 12 sites of the HIV Research Network located in 3 regions of the United States were included.

METHODS

We examined the prevalence of HCV screening, HCV coinfection, direct-acting antiretroviral (DAA) treatment, and SVR-12 between 2014 and 2015. Multivariate logistic regression was performed to identify characteristics associated with outcomes, adjusted for site.

RESULTS

Among 29,071 PWH (age 18-87, 74.8% male, 44.4% black), 77.9% were screened for HCV antibodies; 94.6% of those screened had a confirmatory HCV RNA viral load test. Among those tested, 61.1% were determined to have chronic HCV. We estimate that only 23.4% of those eligible for DAA were prescribed DAA, and only 17.8% of those eligible evidenced initiating DAA treatment. Those who initiated treatment achieved SVR-12 at a rate of 95.2%. Blacks and people who inject drugs (PWID) were more likely to be screened for HCV than whites or those with heterosexual risk. Persons older than 40 years, whites, Hispanics, and PWID [adjusted odds ratio (AOR) 8.70 (7.74 to 9.78)] were more likely to be coinfected than their counterparts. When examining treatment with DAA, persons older than 50 years, on antiretroviral therapy [AOR 2.27 (1.11 to 4.64)], with HIV-1 RNA <400 [AOR 2.67 (1.71 to 4.18)], and those with higher Fib-4 scores were more likely to be treated with DAA.

CONCLUSIONS

Although rates of screening for HCV among PWH are high, screening remains far from comprehensive. Rates of SVR were high, consistent with previously published literature. Additional programs to improve screening and make treatment more widely available will help reduce the impact of HCV morbidity among PWH.

Gonorrhoea and chlamydia in persons with HIV: number needed to screen

OBJECTIVES

Current guidelines recommend screening sexually active persons with HIV (PWH) for Neisseria gonorrhoeae (NG) and Chlamydia trachomatis (CT) at least annually. Yet, screening rates in many HIV clinics remain low. In this study, we estimated the number needed to screen (NNS) to detect a NG and/or CT infection at each anatomic site among different subpopulations of PWH. NNS provides a concrete, practical measure to aid in assessing the practical impact of screening. METHODS : We included adults in care at three HIV Research Network sites in 2011-2014. Restricting to first tests within each year, annual NNS was defined as number of persons tested divided by number positive. We computed urogenital and extragenital NNS by age and risk group (women, men who have sex with women (MSW) and men who have sex with men (MSM)). RESULTS : A total of 16 864 NG/CT tests were included. Among patients aged ≤25 years, urogenital NNS was similar among women (15 (95% CI 6 to 71)), MSW (21 (95% CI 6 to 167)) and MSM (20 (95% CI 12 to 36)). Over 25, urogenital NNS increased to a greater extent for women (363 (95% CI 167 to 1000)) and MSW (160 (95% CI 100 to 333)) than MSM (46 (95% CI 38 to 56)). The increase for women versus MSM >25 remained significant (p<0.01) in multivariable analysis. Among MSM, rectal NNS was 5 (95% CI 3 to 7) and 10 (95% CI 9 to 12) for ≤25 and for >25 years and pharyngeal NNS values were 8 (95% CI 5 to 13) and 20 (95% CI 16 to 24).

CONCLUSIONS

These findings suggest the importance of regular, at least annual NG/CT screening, particularly extragenital, of HIV positive MSM of all ages. They provide some support for age-based cutoffs for women and MSW (eg, universal screening for those aged ≤25 and targeted screening for those aged >25 years).

Contributions of traditional and HIV-related risk factors on non-AIDS-defining cancer, myocardial infarction, and end-stage liver and renal diseases in adults with HIV in the USA and Canada: a collaboration of cohort studies

BACKGROUND

Adults with HIV have an increased burden of non-AIDS-defining cancers, myocardial infarction, end-stage liver disease, and end-stage renal disease. The objective of this study was to estimate the population attributable fractions (PAFs) of preventable or modifiable HIV-related and traditional risk factors for non-AIDS-defining cancers, myocardial infarction, end-stage liver disease, and end-stage renal disease outcomes.

METHODS

We included participants receiving care in academic and community-based outpatient HIV clinical cohorts in the USA and Canada from Jan 1, 2000, to Dec 31, 2014, who contributed to the North American AIDS Cohort Collaboration on Research and Design and who had validated non-AIDS-defining cancers, myocardial infarction, end-stage liver disease, or end-stage renal disease outcomes. Traditional risk factors were tobacco smoking, hypertension, elevated total cholesterol, type 2 diabetes, renal impairment (stage 4 chronic kidney disease), and hepatitis C virus and hepatitis B virus infections. HIV-related risk factors were low CD4 count (<200 cells per μL), detectable plasma HIV RNA (>400 copies per mL), and history of a clinical AIDS diagnosis. PAFs and 95% CIs were estimated to quantify the proportion of outcomes that could be avoided if the risk factor was prevented.

FINDINGS

In each of the study populations for the four outcomes (1405 of 61 500 had non-AIDS-defining cancer, 347 of 29 515 had myocardial infarctions, 387 of 35 044 had end-stage liver disease events, and 255 of 35 620 had end-stage renal disease events), about 17% were older than 50 years at study entry, about 50% were non-white, and about 80% were men. Preventing smoking would avoid 24% (95% CI 13-35) of these cancers and 37% (7-66) of the myocardial infarctions. Preventing elevated total cholesterol and hypertension would avoid the greatest proportion of myocardial infarctions: 44% (30-58) for cholesterol and 42% (28-56) for hypertension. For liver disease, the PAF was greatest for hepatitis C infection (33%; 95% CI 17-48). For renal disease, the PAF was greatest for hypertension (39%; 26-51) followed by elevated total cholesterol (22%; 13-31), detectable HIV RNA (19; 9-31), and low CD4 cell count (13%; 4-21).

INTERPRETATION

The substantial proportion of non-AIDS-defining cancers, myocardial infarction, end-stage liver disease, and end-stage renal disease outcomes that could be prevented with interventions on traditional risk factors elevates the importance of screening for these risk factors, improving the effectiveness of prevention (or modification) of these risk factors, and creating sustainable care models to implement such interventions during the decades of life of adults living with HIV who are receiving care.

FUNDING

National Institutes of Health, US Centers for Disease Control and Prevention, the US Agency for Healthcare Research and Quality, the US Health Resources and Services Administration, the Canadian Institutes of Health Research, the Ontario Ministry of Health and Long Term Care, and the Government of Alberta.

Uptake and virological outcomes of single- versus multi-tablet antiretroviral regimens among treatment-naïve youth in the HIV Research Network

OBJECTIVES

Several single-tablet regimens (STRs) are now available and are recommended for first-line antiretroviral therapy (ART); however, STR use for youth with HIV (YHIV) has not been systematically studied. We examined the characteristics associated with initiation of STRs versus multi-tablet regimens (MTRs) and the virological outcomes for youth with nonperinatally acquired HIV (nPHIV).

METHODS

A retrospective cohort study of nPHIV youth aged 13-24 years initiating ART between 2006 and 2014 at 18 US HIV clinical sites in the HIV Research Network was performed. The outcomes measured were initiation of STRs versus MTRs, virological suppression (VS) at 12 months, and time to VS. Demographic and clinical factors associated with initiation of STR versus MTR ART and VS (< 400 HIV-1 RNA copies/mL) at 12 months after initiation were assessed using multivariable logistic regression. Cox proportional hazards regression was used to assess VS within the first year.

RESULTS

Of 987 youth, 67% initiated STRs. Of the 589 who had viral load data at 1 year, 84% of those on STRs versus 67% of those on MTRs achieved VS (P < 0.01). VS was associated with STR use [adjusted odds ratio (AOR) 1.61; 95% confidence interval (CI) 1.01-2.58], white (AOR 2.41; 95% CI 1.13-5.13) or Hispanic (AOR 2.38; 95% CI 1.32-4.27) race/ethnicity, and baseline CD4 count 351-500 cells/μL (AOR 1.94; 95% CI 1.18-3.19) and > 500 cells/μL (AOR 1.76; 95% CI 1.0-3.10). STR use was not associated with a shorter time to VS compared with MTR use [hazard ratio (HR) 1.07; 95% CI 0.90-1.28].

CONCLUSIONS

Use of STR was associated with a greater likelihood of sustained VS 12 months after ART initiation in YHIV.

Development and content validation of measures assessing adherence barriers and behaviors for use in clinical care

BACKGROUND

Providers are often unaware of poor adherence to prescribed medications for their patients with chronic diseases.

OBJECTIVE

To develop brief, computer-administered patient-reported measures in English and Spanish assessing adherence behaviors and barriers. Design, Participants, and Main Measures: Item pools were constructed from existing measures of medication adherence behaviors and barriers, which informed development of a patient concept elicitation interview guide to identify medication adherence behavior and barrier-related concepts. Two hundred six patients either living with HIV (PLWH) or without were interviewed. Interviews were coded, concepts matched to item pool content, and new items were developed for novel concepts. A provider/investigator team highlighted clinically relevant items. Cognitive interviews were conducted with patients on final candidate items (n = 37). The instruments were administered to 2081 PLWH.

KEY RESULTS

Behavioral themes from concept elicitation interviews included routines incorporating time of day, placement, visual cues, and intentionality to miss or skip doses. Barrier themes included health-related (e.g. depressed mood, feeling ill), attitudes/beliefs (e.g., need for medication), access (e.g., cost/insurance problems), and circumstantial barriers (e.g., lack of privacy, disruption of daily routine). The final instruments included 6 behavior items, and 1 barrier item with up to 23 response options. PLWH endorsed a mean (SD) of 3.5 (1.1) behaviors. The 201 PLWH who missed ≥2 doses in the previous week endorsed a mean (SD) of 3.1 (2.5) barriers. The intraclass correlation coefficient (ICC) for the numbers of behaviors endorsed in 61 PLWH after 4-16 days was 0.54 and for the number of barriers for the 20 PLWH with ≥2 missed doses the ICC was 0.89, representing fair and excellent test-retest reliability.

CONCLUSION

Measures of medication adherence behaviors and barriers were developed for use with patients living with chronic diseases focusing on clinical relevance, brevity, and content validity for use in clinical care.

Medication understanding among patients living with multiple chronic conditions: Implications for patient-reported measures of adherence

BACKGROUND

Low health literacy is associated with poor medication adherence and poor health outcomes. Limited understanding of prescribed medications may decrease validity of patient-reported adherence measures.

OBJECTIVES

To assess knowledge of names and purposes of prescribed medications among patients with multiple chronic conditions.

METHODS

Individual interviews were conducted with a convenience sample of patients from six U.S. primary care clinics. Participants (n = 57) were English and/or Spanish-speaking patients prescribed 3+ medications for chronic conditions, for which non-adherence may lead to disability or death. In individual interviews, patients were asked to name their medications, explain the purpose of each, and to explain how they distinguish them from one another. Interviews were audio recorded, transcribed, and coded; coded content was quantified by 1) whether or not the patient could name medications; 2) method of categorizing medications; 3) whether or not the purpose of the medication was understood. Descriptive statistics were compiled using Fisher's exact test to determine the relationship between patient knowledge and medication characteristics.

RESULTS

Thirty percent of patients could not name at least one of their medications; 19% did not know their purpose; 30% held misconceptions about the purpose of one or more medications. There was no significant difference in ability to name medications or state their medication's purpose between patients using medi-sets, pre-packaged rolls, or blister packs, and patients who stored pills in their original containers (p = 0.56 and p = 0.73, respectively), or across demographic groups (p = 0.085 to 0.767).

CONCLUSIONS

Many patients demonstrated difficulty identifying the name and purpose of prescribed medications; this did not differ by demographic group or medication storage type. Patients may benefit from routine review of medications with their provider in order to improve health literacy, outcomes, and patient-reported adherence measurement.

Provider perceptions of the value of same-day, electronic patient-reported measures for use in clinical HIV care

Strong evidence suggests that patient-reported outcomes (PROs) aid in managing chronic conditions, reduce omissions in care, and improve patient-provider communication. However, provider acceptability of PROs and their use in clinical HIV care is not well known. We interviewed providers (n = 27) from four geographically diverse HIV and community care clinics in the US that have integrated PROs into routine HIV care, querying perceived value, challenges, and use of PRO data. Perceived benefits included the ability of PROs to identify less-observable behaviors and conditions, particularly suicidal ideation, depression, and substance use; usefulness in agenda setting prior to a visit; and reduction of social desirability bias in patient-provider communication. Challenges included initial flow integration issues and ease of interpretation of PRO feedback. Providers value same-day, electronic patient-reported measures for use in clinical HIV care with the condition that PROs are (1) tailored to be the most clinically relevant to their population; (2) well integrated into clinic flow; and (3) easy to interpret, highlighting chief patient concerns and changes over time.

HIV primary care providers--Screening, knowledge, attitudes and behaviors related to alcohol interventions

BACKGROUND

Alcohol has particularly harmful health effects in HIV-infected patients; therefore, HIV clinics are an important setting for integration of brief alcohol intervention and alcohol pharmacotherapy to improve patient outcomes. Current practices of alcohol screening, counseling, and prescription of pharmacotherapy by HIV providers are unknown.

METHODS

We conducted a cross-sectional survey of HIV providers from 8 HIV clinical sites across the United States. Surveys queried knowledge and use of alcohol screening, brief advice, counseling and pharmacotherapy, confidence and willingness to prescribe pharmacotherapy and barriers to their use of alcohol pharmacotherapy. We used multivariable logistic regression to examine provider factors associated with confidence and willingness to prescribe pharmacotherapy.

RESULTS

Providers (N=158) were predominantly female (58%) and Caucasian (73%); almost half were infectious disease physicians and 31% had been in practice 10-20 years. Most providers (95%) reported always or usually screening for alcohol use, although only 10% reported using a formal screening tool. Over two-thirds never or rarely treated alcohol-dependent patients with pharmacotherapy themselves. Most (71%) referred alcohol-dependent patients for treatment. Knowledge regarding alcohol pharmacotherapy was low. The major barrier to prescribing pharmacotherapy was insufficient training on use of pharmacotherapy. Provider confidence ratings were positively correlated with their practice patterns.

CONCLUSIONS

HIV providers reported high rates of screening for alcohol use, though few used a formal screening tool. Most providers referred alcohol dependent patients to outside resources for treatment. Few reported prescribing alcohol pharmacotherapy. Increased training on alcohol pharmacotherapy may increase confidence in prescribing and use of these medications in HIV care settings.

Effects of Referral Bias on Estimates of Anal Intraepithelial Neoplasia Progression and Regression Rates in a 3-State Markov Model

The study aim is to compare anal intraepithelial neoplasia (AIN) progression and regression rates in a cytology inception cohort to estimates based on the subcohort referred for ≥1 high-resolution anoscopies (HRAs).A cytology-based retrospective cohort was assembled including the anal cytology histories and invasive anal cancer (IAC) outcomes of all HIV-infected adults under care between 2001 and 2012. A 3-state Markov model (<HSIL↔HSIL→IAC) was estimated separately for all patients and for the subcohort undergoing ≥ 1 HRAs with biopsy. Cytology was adjusted for misclassification. State transition rates (per person-year) and covariate hazard ratios were estimated using the R package msm.Of 2804 eligible patients in the inception cohort, 629 (22%) were in the HRA subcohort and 2175 (78%) in the non-HRA subcohort. Patients in the HRA subcohort were more likely to have baseline CD4<350, viral load >400, and to have HSIL at baseline and thereafter. They also had more anal cytology examinations (median 6 vs 3) and longer follow-up (median 5.5 vs 3.6 years). State transition rates were overestimated in the HRA subcohort relative to inception cohort, but the degree of discordance varied by transition: for <HSIL to HSIL (0.44 vs 0.04); for HSIL to <HSIL (0.56 vs 0.17); and for HSIL to IAC (0.014 vs 0.011). Beneficial covariate effects on the <HSIL to HSIL transition were concordant (P < 0.05) for time-updated HIV viral load, CD4 count, and antiretroviral therapy. The observed effects of HRA-triage bias may be relevant to estimates of AIN state transitions from other cohorts subject to referral bias.

Lessons learned from the design and implementation of myocardial infarction adjudication tailored for HIV clinical cohorts

We developed, implemented, and evaluated a myocardial infarction (MI) adjudication protocol for cohort research of human immunodeficiency virus. Potential events were identified through the centralized Centers for AIDS Research Network of Integrated Clinical Systems data repository using MI diagnoses and/or cardiac enzyme laboratory results (1995-2012). Sites assembled de-identified packets, including physician notes and results from electrocardiograms, procedures, and laboratory tests. Information pertaining to the specific antiretroviral medications used was redacted for blinded review. Two experts reviewed each packet, and a third review was conducted if discrepancies occurred. Reviewers categorized probable/definite MIs as primary or secondary and identified secondary causes of MIs. The positive predictive value and sensitivity for each identification/ascertainment method were calculated. Of the 1,119 potential events that were adjudicated, 294 (26%) were definite/probable MIs. Almost as many secondary (48%) as primary (52%) MIs occurred, often as the result of sepsis or cocaine use. Of the patients with adjudicated definite/probable MIs, 78% had elevated troponin concentrations (positive predictive value = 57%, 95% confidence interval: 52, 62); however, only 44% had clinical diagnoses of MI (positive predictive value = 45%, 95% confidence interval: 39, 51). We found that central adjudication is crucial and that clinical diagnoses alone are insufficient for ascertainment of MI. Over half of the events ultimately determined to be MIs were not identified by clinical diagnoses. Adjudication protocols used in traditional cardiovascular disease cohorts facilitate cross-cohort comparisons but do not address issues such as identifying secondary MIs that may be common in persons with human immunodeficiency virus.

Community HIV-1 drug resistance is associated with transmitted drug resistance

OBJECTIVES

As community viral load (CVL) measurements are associated with the incidence of new HIV-1 infections in a population, we hypothesized that similarly measured community drug resistance (CDR) could predict the prevalence of transmitted drug resistance (TDR).

METHODS

Between 2001 and 2011, the prevalences of HIV-1 drug resistance for patients with established infection receiving HIV care (i.e. CDR) and TDR in recently infected patients were determined in San Diego. At each position in HIV-1 reverse transcriptase (RT) and protease (pro), drug resistance was evaluated both as the overall prevalence of resistance-associated mutations and by weighting each resistance position to the concurrent viral load of the patient and its proportion to the total viral load of the clinic (CVL). The weighting was the proportion of the CVL associated with patients identified with resistance at each residue. Spearman ranked correlation coefficients were used to determine associations between CDR and TDR.

RESULTS

We analysed 1088 resistance tests for 971 clinic patients and baseline resistance tests for 542 recently infected patients. CDR at positions 30, 46, and 88 in pro was associated with TDR between 2001 and 2011. When CDR was weighted by the viral load of patients, CDR was associated with TDR at position 103 in RT. Each of these associations was corroborated at least once using shorter measurement intervals.

CONCLUSIONS

Despite evaluation of a limited percentage of chronically infected patients in San Diego, CDR correlated with TDR at key resistance positions and therefore may be a useful tool with which to predict the prevalence of TDR.

Human papillomavirus, anal cancer, and screening considerations among HIV-infected individuals

Invasive anal cancer has become an important cause of non AIDS-related cancer among HIV-infected individuals. Human papillomavirus is the main etiological agent. This review explains the pathophysiologic role of human papillomavirus in the development of invasive anal cancer, summarizes recent epidemiological trends of invasive anal cancer, and reviews the evidence to address common clinical questions posed when screening for anal cancer in HIV-infected patients. The effect of highly active antiretroviral therapy on human papillomavirus oncogenesis is still unclear, but given the increased clinical burden of invasive anal cancer among HIV-infected patients, many clinics have implemented screening programs for anal cancer and its precursors. Despite the availability of several modalities for treatment of precursors of anal cancer, evidence that current treatment modalities favorably alter the natural history of human papillomavirus oncogenesis in the anal and perianal regions is still inconclusive. However, there is sufficient evidence to state that the accuracy of anal cancer screening procedures (cytology and high-resolution anoscopy directed biopsy) is comparable to the accuracy of those used in screening for cervical cancer precursors. Studies that systematically assess the efficacy of these anal cancer screening programs in reducing the incidence of and morbidity and mortality from invasive anal cancer among HIV-infected patients are needed.

Structures of care in the clinics of the HIV Research Network

As the HIV epidemic has evolved to become a chronic, treatable condition the focus of HIV care has shifted from the inpatient to the outpatient arena. The optimal structure of HIV care in the outpatient setting is unknown. Using the HIV Research Network (HIVRN), a federally sponsored consortium of 21 sites that provide care to HIV-infected individuals, this study attempted to: (1) document key features of the organization of care in HIVRN adult clinics and (2) estimate variability among clinics in these parameters. A cross-sectional survey of adult clinic directors regarding patient volume, follow-up care, provider characteristics, acute patient care issues, wait times, patient safety procedures, and prophylaxis practices was conducted from July to December 2007. All 15 adult HIVRN clinic sites responded: 9 academic and 6 community-based. The results demonstrate variability in key practice parameters. Median (range) of selected practice characteristics were: (1) annual patient panel size, 1300 (355-5600); (2) appointment no-show rate, 28% (8%-40%); (3) annual loss to follow-up, 15% (5%-25%); (4) wait time for new appointments, 5 days (0.5-22.5), and follow-up appointment, 8 days (0-30). The majority of clinics had an internal mechanism to handle acute patient care issues and provide a number of onsite consultative services. Nurse practitioners and physician assistants were highly utilized. These data will facilitate improvements in chronic care management of persons living with HIV.

The impact of HIV-associated lipodystrophy on healthcare utilization and costs

Background

HIV disease itself is associated with increased healthcare utilization and healthcare expenditures. HIV-infected persons with lipodystrophy have been shown to have poor self-perceptions of health. We evaluated whether lipodystrophy in the HIV-infected population was associated with increased utilization of healthcare services and increased healthcare costs.

Objective

To examine utilization of healthcare services and associated costs with respect to presence of lipodystrophy among HIV-infected patients.

Methods

Healthcare utilization and cost of healthcare services were collected from computerized accounting records for participants in a body image study among HIV-infected patients treated at a tertiary care medical center. Lipodystrophy was assessed by physical examination, and effects of lipodystrophy were assessed via body image surveys. Demographic and clinical characteristics were also ascertained. Analysis of healthcare utilization and cost outcomes was performed via between-group analyses. Multivariate modeling was used to determine predictors of healthcare utilization and associated costs.

Results

Of the 181 HIV-infected participants evaluated in the study, 92 (51%) had clinical evidence of HIV-associated lipodystrophy according to physician examination. Total healthcare utilization, as measured by the number of medical center visits over the study period, was notably increased among HIV-infected subjects with lipodystrophy as compared to HIV-infected subjects without lipodystrophy. Similarly, total healthcare expenditures over the study period were $1,718 more for HIV-infected subjects with lipodystrophy than for HIV-infected subjects without lipodystrophy. Multivariate modeling demonstrated strong associations between healthcare utilization and associated costs, and lipodystrophy score as assessed by a clinician. Healthcare utilization and associated costs were not related to body image survey scores among HIV-infected patients with lipodystrophy.

Conclusion

Patients with HIV-associated lipodystrophy demonstrate an increased utilization of healthcare services with associated increased healthcare costs as compared to HIV-infected patients without lipodystrophy. The economic and healthcare service burdens of HIV-associated lipodystrophy are significant and yet remain inadequately addressed by the medical community.

Supporting Positive Living and Sexual Health (SPLASH): a clinician and behavioral counselor risk-reduction intervention in a university-based HIV clinic

Effective HIV prevention interventions with HIV-positive persons are paramount to stemming the rate of new infections. This paper describes an HIV-clinic-based demonstration project aimed at decreasing patient HIV-transmission risk behaviors and sexually transmitted infections. Systematic, computer-assisted assessment of patient risk aided primary care providers in delivering prevention messages. Patients at greater risk were referred to an HIV Prevention Specialist for behavioral counseling. Patients completed a computerized behavioral staging assessment to self-identify risk behaviors and readiness to change behaviors and counseling messages were individually tailored based on computer assessment. Challenges to project implementation: primary care provider buy-in, patient privacy concerns during risk assessment, and low participation in behavioral counseling. Forty-six percent of persons completing a risk assessment (2,124) were at risk for HIV transmission. Of 121 patients who scheduled counseling appointments, 42% completed at least one session. Despite challenges, successful implementation of a clinic-based prevention intervention is feasible, particularly with attention to patient and provider concerns.

Measurement Characteristics of Anal Cytology, Histopathology, and High-Resolution Anoscopic Visual Impression in an Anal Dysplasia Screening Program

BACKGROUND

The study aims were (1) to estimate agreement between consecutive anal cytologic examinations, between concurrent cytologic examination and histopathology, and between high-resolution anoscopy (HRA) visual impression and histopathology and (2) to estimate the prevalence of severe dysplasia by concurrent cytologic category.

METHODS

Prospective study of HIV-infected patients receiving anal dysplasia screening as part of routine care. Agreement between measures was estimated by weighted kappa-statistics.

RESULTS

Between July 2000 and September 2003, 1864 patients underwent 2947 anal cytology tests. Excluding unsatisfactory tests (6%), 642 patients had repeat cytologic evaluation and 154 had concurrent cytology tests and biopsy. Using 4-category cytology grading, kappa-agreement between the first 2 cytologic measurements was 0.36. Comparing concurrent cytology tests and biopsy, kappa-agreement was 0.36. Comparing the most severe HRA visual impression and biopsy, kappa-agreement was 0.32. The prevalence of anal intraepithelial neoplasia 3 at biopsy by concurrent cytology category was 0 (cytology normal), 21% (atypical squamous cells of uncertain significance), 27% (low-grade squamous intraepithelial lesion), and 54% (high-grade squamous intraepithelial lesion).

CONCLUSIONS

These data suggest that the reproducibility of key screening measures is moderate at best but of similar magnitude to that of other studies of anal and cervical dysplasia screening. As candidate interventions to treat or prevent precursor lesions enter clinical development, standardization and improvement of measurement methods are essential.

Underuse of primary Mycobacterium avium complex and Pneumocystis carinii prophylaxis in the United States

BACKGROUND

Little is known about the rates of Mycobacterium avium complex (MAC) and Pneumocystis carinii (PCP) prophylaxis adherence to guidelines and how they have changed after introduction of effective antiretroviral therapy.

OBJECTIVE

To determine rates of primary prophylaxis for MAC and PCP and to evaluate the influence of sociodemographic characteristics, region, and provider experience.

DESIGN

National probability sample cohort of HIV patients in care.

SETTING

One hundred sixty HIV health care providers.

PATIENTS

A total of 2864 patients interviewed in 1996 to 1997 (68% response) and 2267 follow-up interviews, representing 65% of surviving sampled patients (median follow-up, 15.1 months).

MEASUREMENTS

Use of prophylactic drugs, most recent CD4 count, sociodemographics, and regional and total HIV patients/providers.

RESULTS

Of patients eligible for primary MAC prophylaxis (most recent CD4 count <50/mm(3) ), 41% at baseline and 40% at follow-up patients were treated. Of patients eligible for primary PCP prophylaxis (i.e., those with CD4 counts <200/mm(3) ), 64% and 72% were treated, respectively. MAC prophylaxis at baseline was less likely in African American (adjusted odds ratio [OR], 35; 95% confidence interval [CI], 0.20-0.59), Hispanic (OR, 27; 95% CI, 0.08-0.94) and less-educated (OR, 0.61; 95% CI, 0.36-1.0) patients and more likely in U. S. geographic regions in the Pacific West (OR, 4.9; 95% CI, 1.0-23) and Midwest (OR, 6.4; 95% CI, 1.2-33) and in practices with more HIV patients.

CONCLUSIONS

Most eligible patients did not receive MAC prophylaxis; PCP prophylaxis rates were better but still suboptimal. Our results support outreach efforts to African Americans, Hispanics, the less educated, and those in the northeastern United States and in practices with fewer HIV patients.

Sinonasal disease and olfactory impairment in HIV disease: endoscopic sinus surgery and outcome measures

OBJECTIVES

To investigate the effects of ESS (ESS) on olfactory impairment, disease-specific symptoms, and general quality of well-being In HIV+ patients with sinonasal disease.

STUDY DESIGN

Study 1: Nasal cytology, rhinomanometry, nasal examination including endoscopy, disease-specific sinonasal symptoms, olfactory threshold sensitivity, and odor identification testing were performed before and after ESS in HIV+ patients with sinonasal complaints. Study 2: Quality of well-being was assessed before and after ESS in HIV+ patients with sinonasal complaints and controls.

RESULTS

Significant olfactory sensitivity loss persisted for patients with chronic sinusitis after ESS, suggesting that the impairment in these patients may be due to viral disease rather than inflammation. Significant improvement in other disease-specific symptom scores (nasal obstruction, nasal congestion, headache, sinus pain, etc.) and results of the general quality of well-being assessment showed ESS to be beneficial in the extended health management of HIV illness.

CONCLUSIONS

The current study indicated both olfactory dysfunction and subjective negative symptoms in HIV+ patients with chronic sinusitis. Although olfactory dysfunction remained, ESS was successful in providing marked alleviation of symptomatology in HIV+ patients with chronic sinusitis. The results support ESS as an appropriate treatment option for HIV+ patients with chronic sinusitis.

National estimates of HIV-related symptom prevalence from the HIV Cost and Services Utilization Study

OBJECTIVES

The objectives of this study were (1) to estimate the prevalence, bothersomeness, and variation of HIV-related symptoms in a nationally representative sample of HIV-infected adults receiving medical care and (2) to evaluate new aggregate measures of symptom frequency and bothersomeness.

METHODS

Beginning in January 1996, 76% of a multistage national probability sample of 4,042 HIV-infected adults receiving medical care were interviewed. Participants endorsed the presence and degree of bothersomeness of 14 HIV-related symptoms during the preceding 6 months. Sex-standardized symptom number and bothersomeness indices were constructed. After sampling weights were incorporated, symptom distributions were compared according to selected characteristics by analysis of variance and multiple linear regression modeling.

RESULTS

Prevalence of specific symptoms in the reference population was as follows: fever/night sweats, 51.1%; diarrhea, 51%; nausea/anorexia, 49.8%; dysesthesias, 48.9%; severe headache, 39.3%; weight loss, 37.1%; vaginal symptoms, 35.6% of women; sinus symptoms, 34.8%; eye trouble, 32.4%; cough/dyspnea, 30.4%; thrush, 27.3%; rash, 24.3%; oral pain, 24.1%; and Kaposi's sarcoma, 4%. Aggregate measures were reliable (Cronbach's alpha > or =0.75) and demonstrated construct validity when compared with other measures of disease severity. After adjustment for CD4 count, both symptom number and bothersomeness varied significantly (P <0.05) by teaching status of care setting, exposure/risk group, educational achievement, sex, annual income, employment, and insurance category. However, the magnitude of variation was small. Symptoms were greatest in women and injection drug users, as well as in persons with lower educational levels, lower income, and Medicare enrollment or those who were followed up at teaching hospitals.

CONCLUSIONS

The prevalence and bothersomeness of HIV-related symptoms are substantial and vary by setting of care and patient characteristics.

Hyperlactatemia and hepatic abnormalities in 10 human immunodeficiency virus-infected patients receiving nucleoside analogue combination regimens

During a 6-and-a-half month period, we identified 10 human immunodeficiency virus (HIV)-infected men who were receiving antiretroviral regimens, including nucleoside analogues, and who developed unexplained reproducible hyperlactatemia in association with either abdominal symptoms or an unaccounted-for elevated alanine aminotransferase level, or both. After careful consideration of the possible etiologies, antiretrovirals were discontinued; lactate levels normalized in all patients. The estimated incidence of this phenomenon in our clinic was 20.9 cases per 1000 person-years of nucleoside analogue treatment. These observations extend the spectrum of the nucleoside analogue-induced lactic acidosis/hepatic steatosis syndrome by the identification of a subtle and perhaps earlier form, which has characteristic symptoms and laboratory abnormalities, and a favorable prognosis on discontinuation of antiretroviral therapy.

Predicting survival in patients with recurrent symptomatic malignant pleural effusions: an assessment of the prognostic values of physiologic, morphologic, and quality of life measures of extent of disease

PURPOSE

To determine the prognostic value of pleural fluid pH, pleural fluid glucose, extent of pleural carcinomatosis (EPC) score, and Karnofsky Performance Scale (KPS) score in patients with recurrent symptomatic malignant pleural effusions.

DESIGN

Prospective 53-month study.

SETTING

Referral center for interventional pulmonology.

PATIENTS

Eighty-five consecutive patients (42 men and 43 women) with recurrent symptomatic malignant pleural effusions who were referred to the interventional pulmonary service for thoracoscopic pleurodesis.

MEASUREMENTS

Pleural fluid pH, pleural fluid glucose, EPC score, and KPS score.

RESULTS

The KPS score was the only statistically significant predictor variable. Patients with a KPS score >/= 70 had a median survival of 395 days, as opposed to a median survival of only 34 days for patients with a KPS score </= 30. No prognostic advantage was evident when patients were categorized by pleural fluid pH, pleural fluid glucose, or EPC score.

CONCLUSION

When assessing the prognosis of a patient with a recurrent symptomatic malignant pleural effusion, only the KPS score at the time of thoracoscopy is predictive of survival. Pleural fluid pH, pleural fluid glucose, and EPC scores are not as reliable as initially reported. For patients with a KPS score >/= 70, it may be very reasonable to proceed with thoracoscopic talc pleurodesis for management of their malignant pleural effusions.

Neutropenia is a risk factor for gram-negative bacillus bacteremia in human immunodeficiency virus-infected patients: results of a nested case-control study

A previous cohort study demonstrated a relation between neutropenia and bacteremia due to gram-negative bacilli among patients infected with human immunodeficiency virus (HIV). To explore further the relation between neutropenia and bacteremia due to Escherichia coli, Klebsiella pneumoniae, or Pseudomonas aeruginosa among HIV-infected patients, controlling for confounding factors, the authors conducted a nested case-control study with matching and risk-set sampling of controls. The cohort included 1,645 HIV-infected patients followed at the University of California, San Diego, Medical Center in San Diego, California, between 1991 and 1995. Absolute neutrophil count (ANC) was summarized as mean ANC during the 7-day interval preceding the index date of bacteremia. Covariates were ascertained by medical record review. The matching ratio was 6:1 (controls:cases). Odds ratios were estimated using conditional logistic regression. Forty-four incident cases of bacteremia were identified. After adjustment for covariates, the estimated odds ratio for the effect of neutropenia (ANC=500 vs. >500/microl) during the 7 days preceding the index date was 8.1 (95% confidence interval confidence interval 1.5-43.1). The rate of bacteremia due to E. coli, K. pneumoniae, or P. aeruginosa is increased eightfold if the average current-week ANC is less than or equal to 500/microl compared with more than 500/microl.

Estimation of the effect of neutropenia on rates of clinical bacteraemia in HIV-infected patients

A retrospective cohort study was conducted to quantitate the relationship between neutropenia and rates of clinical bacteraemia among adults with HIV infection receiving medical care at one institution between 1991-5. The primary exposure, absolute neutrophil count (ANC), was summarized as mean ANC within a given week, using a five-level stratification (reference > 1000/microl). ANC stratum-specific rates of bacteraemia were calculated, by organism type. Linear trend tests were performed to assess dose-response relationship between neutropenia and rates of bacteraemia. The cohort included 1645 patients contributing 26,785 patients-weeks and 191 episodes of bacteraemia. The unadjusted effect of neutropenia was most evident for bacteraemia due to E. coli (RR 3.4), Klebsiella pneumoniae (RR 16.7), and P. aeruginosa (RR 10.4). For bacteraemia due to any of these three organisms (47 episodes), with reference ANC > 1000/microl, relative rates were: 751-1000/microl, 1.12; 501-750/microl, 2.11; 251-500/microl, 13.58; 0-250/microl, 21.89.

Treatment adequacy for HIV-related pneumocystis pneumonia: quality measures for inpatient care

To develop and evaluate severity-adjusted indicators of treatment timeliness and adequacy for inpatient care of first episode of HIV-related pneumocystis pneumonia, a retrospective cohort study (n = 414) using medical record review was conducted in six California medical centers (1 January 1983-30 June 1987). Measures included patient baseline characteristics and complexity, process-of-care indicators (delay in treatment initiation and proportion of adequate treatment delivered), and overall survival of hospitalization and survival without respiratory failure. Logistic regression models of severity were developed among optimally treated patients and cross-validated. Exposure to medication with pneumocystis activity within 30 days prior to admission was protective. After controlling for pre-admission medication and severity, the average proportion of adequate pneumocystis medication delivered during the first 7 and 30 days were significant predictors of outcome in all models. Delay in treatment initiation, while not a statistically significant predictor, was associated with baseline severity. Summary measures of treatment adequacy show promise as process-of-care indicators.

The scratch test is unreliable for detecting the liver edge

To determine the validity and reliability of the scratch test method for estimating the liver span below the right costal margin, we performed a prospective double-blind study using multiple examiners at different levels of training. Twenty-two patients were examined by 11 observers using only the scratch test. Measures of liver edge length below the right costal margin using the scratch test were compared with those by ultrasound. The validity of the scratch test was determined by simple linear regression and the concordance correlation coefficient. There was very poor correlation between the scratch test estimates and ultrasound measurements for all examiners. Measurement reliability, estimated using generalizability theory, for seven observers who examined the same nine patients was 0.68. The reliability of a single examiner was 0.24. The scratch test method for measuring the liver edge span below the right costal margin was neither a valid nor reliable method of physical examination.

Cutaneous Acanthamoeba infection in the acquired immunodeficiency syndrome: response to multidrug therapy

Acanthamoeba, a free-living ameba of soil and water, produces the rare infections of granulomatous amebic encephalitis and amebic keratitis. We report a 38-year-old white man with the acquired immunodeficiency syndrome (AIDS) who experienced Acanthamoeba infection that presented as multiple skin nodules without associated encephalitis. Histologic examination revealed necrotizing granulomatous inflammation with numerous amebic organisms that were cultured and identified as Acanthamoeba group 2, probably Acanthamoeba castellani by monoclonal antibodies. Results of in vitro susceptibility testing demonstrated resistance to all six tested drugs. A partial clinical response, however, was obtained with multidrug therapy.

Use of a clinical laboratory database to estimate Toxoplasma seroprevalence among human immunodeficiency virus-infected patients. Overcoming bias in secondary analysis of clinical records

Knowledge of Toxoplasma seroprevalence among human immunodeficiency virus-infected patients identifies candidates for potential prophylaxis and may influence management among patients who present with mass lesions of the central nervous system. Toxoplasma antibody seroprevalence among persons with human immunodeficiency virus infection varies widely. We utilized an administrative and laboratory database (including 1599 patients with human immunodeficiency virus infection who were receiving medical care at the University of California-San Diego Medical Center, between July 1, 1986, and March 31, 1990) to estimate Toxoplasma seroprevalence. Of the 1599 patients, 344 underwent serum assays for Toxoplasma antibodies. The tested group was similar to other members of the cohort in distributions of sex, race, citizenship, and age. The overall mean (+/- SE) Toxoplasma seroprevalence was 16% +/- 2%. Potential bias in this estimate because of testing indication, misclassification, or testing frequency was small.

Rapid clinical diagnosis of pulmonary abnormalities in HIV-seropositive patients by auscultatory percussion

A prospective, blinded study of pulmonary findings in hospitalized patients with HIV infection compared auscultatory percussion (AusP) with conventional percussion (ConP) and conventional auscultation (ConA) using chest radiographs as the gold standard. Sixty-three patients had chest radiographs and were examined by one to three examiners. Seventy of the 126 lungs had radiographic abnormalities (55.6 percent). Auscultatory percussion proved to be the most sensitive of all techniques for each examiner (range, 51.0 to 69.6 percent) for detecting radiographic abnormalities and also had higher likelihood ratios for two of the three examiners; AusP also had the highest likelihood ratio pooled across examiners. Of the 166 abnormal results of lung examinations, the combination of AusP and ConA detected 31 more abnormalities than ConP and ConA combined, with 14 of these being diagnosed with Pneumocystis carinii pneumonia. No abnormalities were detected by ConP that were not detected by AusP. These findings suggest that AusP, a rapid clinical maneuver, is more sensitive and specific than ConA and ConP in determining pulmonary abnormalities in HIV-infected inpatients.

Correlation between CD4+ counts and prevalence of cytomegalovirus retinitis and human immunodeficiency virus-related noninfectious retinal vasculopathy in patients with acquired immunodeficiency syndrome

We prospectively studied 132 patients with acquired immunodeficiency syndrome (AIDS) to determine the cross-sectional prevalence of cytomegalovirus retinitis. All patients had serum CD4+ lymphocyte counts to determine the degree of immune dysfunction. Correlations between CD4+ counts, the presence of cytomegalovirus retinitis or human immunodeficiency virus (HIV)-related noninfectious retinal vasculopathy, and ocular symptoms were made. The study disclosed that 26 of 132 patients with AIDS (20%) had cytomegalovirus retinitis. However, subset analysis according to CD4+ count disclosed that in patients with CD4+ counts of 50 cells/mm3 or less, 26 of 87 (30%) had cytomegalovirus retinitis, whereas in patients with CD4+ counts of 50 cells/mm3 or more, none of 45 was noted to have cytomegalovirus retinitis. Similarly, 46 of 132 patients (35%) were noted to have HIV-related noninfectious retinal vasculopathy, with a trend toward increasing prevalence associated with declining CD4+ count. In patients with CD4+ counts of 50 cells/mm3 or less, 39 of 87 (45%) had HIV-related noninfectious retinal vasculopathy, whereas seven of 45 patients (16%) with CD4+ counts of 50 cells/mm3 or more were noted to have these changes. We confirmed the clinical impression that cytomegalovirus retinitis and HIV-related noninfectious retinal vasculopathy are late manifestations of AIDS, demonstrated an increased risk for patients with low CD4+ counts, and suggested a basis for coherent chemoprophylaxis and screening strategies for cytomegalovirus retinitis.

Functional status and well-being in a placebo-controlled trial of zidovudine in early symptomatic HIV infection

To determine the effect of zidovudine on functional status and well-being in patients with early symptomatic human immunodeficiency virus (HIV) infection, 70 subjects in a randomized, placebo-controlled trial (ACTG Protocol 016) were observed for 1 year using a brief quality-of-life questionnaire. Thirty-four subjects were assigned to placebo and 36 subjects to zidovudine, 200 mg orally every 4 h (1,200 mg daily). Functional status and well-being were measured every 3 months using a 30-item self-administered questionnaire derived from health ratings from the Medical Outcomes Study. The mean changes from baseline for zidovudine versus placebo groups were compared using paired and two-sample t tests. Subjects receiving a placebo reported better quality of life compared to baseline than subjects receiving zidovudine at 24 weeks for all dimensions of well-being, including overall health, energy, mental health, health distress, pain, and quality of life. The difference between the two groups' changes from baseline for overall health was 11.5 points on a 100-point scale (p = 0.02), and 11.1 points for energy (0.002). There were no differences between changes from baseline along various dimensions of functional status (physical, social, role, and cognitive function). At 52 weeks both groups reported worse overall health than at baseline, and changes in scores were more similar for the two groups. Although zidovudine has previously been demonstrated to delay progression of disease for patients with mildly symptomatic HIV infection, early in treatment the net effect of a 1,200 mg daily dose of zidovudine may diminish patients' subjective well-being.(ABSTRACT TRUNCATED AT 250 WORDS)

Examiner dependence on physical diagnostic tests for the detection of splenomegaly: a prospective study with multiple observers

OBJECTIVE

To determine the reliability and validity of various physical diagnostic techniques (including three methods of palpation and three methods of percussion) in detecting ultrasonographically identified splenomegaly.

DESIGN

Prospective, double-blind study.

SETTING

University hospital.

PATIENTS

Twenty-seven hospitalized male patients with suspected human immunodeficiency virus (HIV) infection.

INTERVENTIONS

Three methods of palpation (bimanual, ballottement, and palpation from above) and three methods of percussion (as described by Nixon, Castell, and Barkun et al.) were performed on each patient by eight examiners. Splenic ultrasonography was performed within 96 hours of admission.

MEASUREMENTS AND MAIN RESULTS

The prevalence of splenomegaly by ultrasonography (defined as a spleen > or = 13 cm on the longitudinal scan) in this population was 33.3%. The sensitivity and specificity of each method of palpation and percussion varied by examiner. The ranges of sensitivity across examiners for the three methods of palpation and the three methods of percussion were 0%-64.3% and 7.7%-75%, respectively. The ranges of specificity across examiners for the three methods of palpation and the three methods of percussion were 50%-100% and 60%-100%, respectively. Likelihood ratios pooled across observers revealed that for palpation, palpation from above, and percussion, Castell's method had the highest likelihood ratios [LR = 2.66 and 1.97, respectively; 95% CI = 1.52-4.64 and 1.22-3.19, respectively]. A combination of tests (either palpation or percussion) increased the diagnostic accuracy.

CONCLUSION

Physical diagnostic techniques for the detection of splenomegaly are relatively insensitive but specific. In this study there was high interobserver variability, which did not appear to be associated to the level of experience. Combining tests increases diagnostic accuracy.

Primary cutaneous aspergillosis near central venous catheters in patients with the acquired immunodeficiency syndrome

BACKGROUND

Aspergillosis in patients with the acquired immunodeficiency syndrome is unusual, and the clinicopathologic features of primary cutaneous aspergillosis in this setting are undefined. Our findings show that the manifestations can differ from those of primary cutaneous aspergillosis in other immunocompromised patients.

OBSERVATIONS

Two men with the acquired immunodeficiency syndrome developed foci of primary cutaneous aspergillosis beneath adhesive tape near central venous catheter sites. Typical lesions were flesh-colored to pink, umbilicated papules that clinically resembled molluscum contagiosum. Biopsy specimens showed variably ruptured follicles that contained collections of fungal hyphae typical of Aspergillus species. Cultures in one case identified Aspergillus fumigatus. The use of nonocclusive dressings and local wound care resulted in involution of several lesions.

CONCLUSIONS

Primary cutaneous aspergillosis begins as saprophytic involvement of hair follicles secondary to the altered microenvironment beneath adhesive tape. Systemic antifungal therapy is prudent, but in the absence of neutropenia or other traditional risk factors for dissemination, it appears that Aspergillus in patients with the acquired immunodeficiency syndrome can produce relatively indolent cutaneous lesions with a tendency to resolve once precipitating factors are removed.

Pneumocystis carinii peritonitis. Antemortem confirmation of disseminated pneumocystosis by cytologic examination of body fluids

Histologic confirmation of extrapulmonary Pneumocystis carinii infection in the acquired immunodeficiency syndrome has usually required organ biopsy when the diagnosis was made antemortem. Three cases of Pneumocystis peritonitis were studied in which confirmation of extrapulmonary dissemination was achieved by cytologic examination of ascitic fluid. Patients presented with characteristic choroidal lesions, transudative ascites, profound hypoalbuminemia, and hepatic dysfunction. Cytologic examination of ascitic fluid confirmed extrapulmonary dissemination of pneumocystis. All three patients died despite a minimum of 2 weeks of standard therapy. Cytologic examination of body fluids to confirm dissemination of Pneumocystis may obviate the need for organ biopsy. Disseminated pneumocystosis should be included in the differential diagnosis of ascites or peritonitis in a patient at risk for human immunodeficiency virus--associated opportunistic infections. The presence of transudative ascites may be characteristic of this syndrome.

A health status questionnaire using 30 items from the Medical Outcomes Study. Preliminary validation in persons with early HIV infection

Many current health status instruments either are too long to use in many acquired immune deficiency syndrome (AIDS) clinical trials or omit important concepts. In this study, human immunodeficiency virus (HIV)-relevant items developed for the Medical Outcomes Study (MOS) from subscales for cognitive function, energy/fatigue, health distress, and a single quality of life item were added to a portion of the MOS Short-form General Health Survey. The resulting 30-item questionnaire reliably and distinctly measured ten aspects of health and took less than 5 minutes to complete. To test its validity, this modified measure was used to compare the health of 73 subjects with asymptomatic HIV infection and 44 with early AIDS-related complex (ARC). Compared with ARC subjects, asymptomatic individuals reported superior overall health, less pain, and better physical function, role function, cognitive function, and quality of life (rank-sum, P less than 0.02). Asymptomatic subjects' scores were higher on most subscales than the age-adjusted scores of MOS outpatients with hypertension, diabetes, recent myocardial infarction, or depression; ARC patients scored closest to hypertensive patients. This instrument, containing a subset of the MOS measures of health-related quality of life, may be a useful outcome measure for AIDS clinical trials.

Longitudinal study of cytomegalovirus retinitis in acquired immune deficiency syndrome

The authors prospectively evaluated 67 consecutive patients with the acquired immune deficiency syndrome (AIDS) and cytomegalovirus (CMV) retinitis during a 33-month period to assess the clinical patterns of retinal infection, efficacy of treatment, long-term survival, and relationship of retinitis to immune function. Immediately sight-threatening retinitis presented in six patients (9%) with peripapillary disease; primary foveal infection was not observed. Eighty-seven percent of patients were treated with ganciclovir. Thirty-nine patients (58%) presented with unilateral disease and contralateral infection developed in 15% of those while on ganciclovir. Smoldering (incompletely responsive) retinitis was seen in 33% of the 21 patients whose retinitis progressed while receiving ganciclovir. Progression of treated retinitis was associated with a lower lymphocyte count (P = 0.04). Median survival after diagnosis of CMV retinitis was 8 months. This represents the largest reported prospective study of CMV retinitis and indicates that (1) CMV infrequently poses an immediate threat to vision on presentation, (2) response to therapy may be related to immune function, and (3) smoldering retinitis should be recognized as an important clinical entity associated with treatment failure.

Recent sexual behaviors among homosexual men seeking primary medical care

We studied the sociodemographic characteristics, knowledge, and beliefs about acquired immunodeficiency syndrome transmission and sexual practices of 823 gay or bisexual men seeking primary care. During the previous 2 months, 64% had engaged in at least one sexual behavior considered unsafe. These patients compared with those having safer sex, were younger, of lower socioeconomic status, and from a racial minority, especially Latino. The unsafe group also had more sexual partners, engaged in sexual acts more often, felt less in control over their sexual behavior, used recreational drugs more frequently, and were less likely to talk about safe sex with partners. The unsafe group had less adequate knowledge about human immunodeficiency virus transmission but felt safer from the risk of acquired immunodeficiency syndrome even when engaging in unsafe sex. Educational programs dealing more directly with belief systems and the potential addiction to recreational drugs and sexual behaviors need to be developed for primary care settings.