A social innovation to empower community-led monitoring and mobilization for HIV prevention in rural Kenya: experimenting to reduce the HIV prevention policy-implementation gap

Introduction

Strong policy guidance has recently emerged identifying focal points at multiple levels and across sectors to end the persistent HIV pandemic and related inequities. Reducing the policy-implementation gap, as with the evidence-policy gap, requires strategic alignment between interventional research and policy realms. Global- and national-level HIV policy indicate a need for community-led efforts to reduce HIV stigma, and increase uptake of HIV prevention tools.

Methods

This study assesses a process-driven approach to facilitating community-led efforts to reduce HIV stigma, and build a generative context for community-led HIV prevention. The study intervention combines an adapted group-based microfinance process, a novel psychological curriculum, and leadership development at a scale now involving over 10,000 rural Kenyans across 39 villages.

Results

Consistent with interventional goals, and current relevant psychosocial theories, we find collective emotion, and HIV stigma (blame and discrimination) significantly improve with more time participating in the in the program and novel curriculum. Further, HIV stigma predicts subsequent reporting of ever being tested for HIV, and the intervention led to the development of "HIV prevention resource committees" - groups of participants committed to undergo training to reduce HIV stigma and prevent HIV within their communities.

Discussion

Implications for further research to reduce the HIV policy-implementation gap are discussed, directly within this interventional context and more generally.

Enabling structural resilience of street-involved children and youth in Kenya: reintegration outcomes and the Flourishing Community model

Introduction

Millions of children and youth live on city streets across the globe, vulnerable to substance use, abuse, material and structural neglect. Structural resilience, the re-establishment of access to structural goods within a society such as housing, education, and healthcare following some interruption, provides an orientation for research and interventional efforts with street-involved children and youth (SICY). Further, a structural resilience framework supports organizing interactions between levels and sectors of a socio-ecology.

Methods

Following the expressed interests of Kenyan SICY, and consistent with emerging policy interests at national and global levels, we assess reintegration trajectories of Kenyan SICY (n = 227) participating in a new program intervention and model. The intervention combines two coordinated, parallel programs - one focused on the rescue, rehabilitation, reintegration and resocialization of SICY, and the other focused on empowering families and communities to provide better care for children and youth who are reintegrating from life on the streets to the broader community. Data were collected and analyzed from multiple stages across SICY involvement with the intervention.

Results

We found 79% of SICY participants reintegrated with the broader community, and 50% reintegrated with families of origin and returned to school. Twenty-five percent of participants reintegrated to a boarding school, polytechnical school, or began a business. Probability of reintegrating successfully was significantly improved among participants whose families participated in the family- and community-oriented program, who were younger, with less street-exposure, expressed more personal interests, and desired to reintegrate with family.

Discussion

To our knowledge, these are the first quantitative data published of successful reintegration of SICY to the broader, non-institutionalized community in any low- or middle-income country. Future research should (1) identify factors across socio-ecological levels and sectors contributing to health and developmental outcomes of reintegrated children and youth, (2) mechanisms to support SICY for whom the interventional strategy did not work, (3) methods to prevent street-migration by children and youth, and (4) system development to coordinate follow-up and relevant investment by institutions, organizations and community leaders to continue reintegration work.

Flourishing Communities: A new model to promote sustainable community leadership and transformation in semi-rural Kenya

Communities often face numerous challenges and opportunities - situations that may be reduced to specific domains by researchers, policy makers and interventionists. This study informs and animate a new "flourishing community" model that seeks to build collective capacity to respond to challenges and opportunities. Our work is a response to children living on the streets, whose families face myriad challenges. The Sustainable Development Goals make explicit the need for new, integrative models that acknowledge the interplay of challenges and opportunities within communities through the flow of everyday life. Flourishing communities are generative, supportive, resilient, compassionate, curious, responsive, self-determined, and build resources across economic, social, educational, and health domains. Integrating theoretical models - specifically, community-led development, multi-systemic resilience, and the "broaden and build" cycle of attachment - provide a testable framework to understand and explore hypothesized relationships between survey-collected, cross-sectional variables with 335 participants. Higher collective efficacy, a common byproduct of group-based microlending activities, was correlated with higher sociopolitical control. This correlation was mediated by higher positive emotion, meaning in life, spirituality, curiosity, and compassion. Further research is required to understand replicability, cross-sectoral impact, mechanisms of integrating health and development domains, and implementation challenges of the flourishing community model. Please refer to the Supplementary Material section to find this article's Community and Social Impact Statement.

Long COVID and mental health correlates: a new chronic condition fits existing patterns

Background

Emerging Long COVID research indicates the condition has major population health consequence. Other chronic conditions have previously been associated with functional and mental health challenges - including depression, anxiety, post-traumatic stress disorder (PTSD), suicide ideation, substance use and lower life satisfaction.

Methods

This study explores correlations between self-reported Long COVID, functional and mental health challenges among a random community-based sample of people (n = 655) aged 20-50 years who contracted COVID-19 prior to vaccination in a Texas county. A random sample of eligible participants was mailed a link to participate in a semi-structured questionnaire. Participant responses, including open-ended responses regarding their experience following COVID-19, were paired with health system data.

Results

Long COVID was associated with increased presence of depression (13% increase), anxiety (28% increase), suicide ideation (10% increase), PTSD (20% increase), and decreased life satisfaction and daily functioning. Structural equation modeling, controlling for sociodemographic variables and imposing a theoretical framework from existing chronic disease research, demonstrated correlations between Long COVID and higher PTSD, suicide ideation and lower life satisfaction were mediated by higher daily functional challenges and common mental disorders.

Conclusions

Basic and applied, interdisciplinary research is urgently needed to characterize the population-based response to the new challenge of Long COVID.

Primary and Secondary Attack Rates by Vaccination Status after a SARS-CoV-2 B.1.617.2 (Delta) Variant Outbreak at a Youth Summer Camp-Texas, June 2021

Children are capable of initiating COVID-19 transmission into households, but many questions remain about the impact of vaccination on transmission. Data from a COVID-19 Delta variant outbreak at an overnight camp in Texas during June 23-27, 2021, were analyzed. The camp had 451 attendees, including 364 youths aged  < 18 years and 87 adults. Detailed interviews were conducted with 92 (20.4%) of consenting attendees and 117 household members of interviewed attendees with COVID-19. Among 450 attendees with known case status, the attack rate was 41%, including 42% among youths; attack rates were lower among vaccinated (13%) than among unvaccinated youths (48%). The secondary attack rate was 51% among 115 household contacts of 55 interviewed index patients. Secondary infections occurred in 67% of unvaccinated household members and 33% of fully or partially vaccinated household members. Analyses suggested that household member vaccination and camp attendee masking at home protected against household transmission.

Adverse childhood experiences, adult anxiety and social capital among women in rural Kenya

Hundreds of millions of people suffer anxiety disorders globally, demonstrating need for scalable and effective interventions. Adverse childhood experiences contribute to this mental health burden. The stress-buffering hypothesis, which posits social factors moderate prior adversity and subsequent mental health outcomes, provides one theoretical avenue to consider observations that group-based microfinance programs improve social capital. We investigate associations between adverse childhood experiences, generalized anxiety among adults and social capital associated with participation in a group-based microfinance program in rural Kenya. Adult participants (n = 400 women) responded to standardized measures of childhood adversity in June 2018, group-affiliated social capital and generalized anxiety in June 2019. Cumulative adverse childhood experiences predicted higher anxiety, which was statistically moderated by the presence of group-affiliated interpersonal trust. This study is the first to find social capital associated with participation in a group-based microfinance program statistically moderates expected associations between adverse childhood experiences and adult generalized anxiety. Future study should be conducted using a cluster-randomized control design to further assess the potential of this intervention method to ameliorate associations between past adversity and current mental health.

Prediction of the need for intensive oxygen supplementation during hospitalisation among subjects with COVID-19 admitted to an academic health system in Texas: a retrospective cohort study and multivariable regression model

OBJECTIVE

SARS-CoV-2 has caused a pandemic claiming more than 4 million lives worldwide. Overwhelming COVID-19 respiratory failure placed tremendous demands on healthcare systems increasing the death toll. Cost-effective prognostic tools to characterise the likelihood of patients with COVID-19 to progress to severe hypoxemic respiratory failure are still needed.

DESIGN

We conducted a retrospective cohort study to develop a model using demographic and clinical data collected in the first 12 hours of admission to explore associations with severe hypoxemic respiratory failure in unvaccinated and hospitalised patients with COVID-19.

SETTING

University-based healthcare system including six hospitals located in the Galveston, Brazoria and Harris counties of Texas.

PARTICIPANTS

Adult patients diagnosed with COVID-19 and admitted to one of six hospitals between 19 March and 30 June 2020.

PRIMARY OUTCOME

The primary outcome was defined as reaching a WHO ordinal scale between 6 and 9 at any time during admission, which corresponded to severe hypoxemic respiratory failure requiring high-flow oxygen supplementation or mechanical ventilation.

RESULTS

We included 329 participants in the model cohort and 62 (18.8%) met the primary outcome. Our multivariable regression model found that lactate dehydrogenase (OR 2.36), Quick Sequential Organ Failure Assessment score (OR 2.26) and neutrophil to lymphocyte ratio (OR 1.15) were significant predictors of severe disease. The final model showed an area under the curve of 0.84. The sensitivity analysis and point of influence analysis did not reveal inconsistencies.

CONCLUSIONS

Our study suggests that a combination of accessible demographic and clinical information collected on admission may predict the progression to severe COVID-19 among adult patients with mild and moderate disease. This model requires external validation prior to its use.

Childhood Experiences and Intimate Partner Violence Among Kenyan Males: Mediation by Self-Esteem and Impulsivity

This study evaluates associations between childhood social environments and current intimate partner conflict tactics in early adulthood. The subsample for this study (n = 251 men) were participants in a larger community-based study of men's mental and behavioral health in semirural Kenya. A survey questionnaire was administered by trained interviewers, including validated recall measures from childhood, collective self-esteem and impulsivity, and the conflict tactics scale short form. Analyses utilized regression and mediation methods. The recall measures evaluated the degree of relational warmth and safety recalled from early childhood and forms of abuse, neglect and dysfunction present in the childhood home. Collective self-esteem assessed the perceived value of one's social groups and one's value as a member of these groups. Impulsivity measured the propensity to act without thinking. The conflict tactics scale evaluates the presence and frequency of specific behaviors following intimate partner conflict, which lead to two factors-negotiation-based tactics and violence tactics. More early memories of relational warmth, responsiveness, and safety during childhood predict fewer violent intimate conflict tactics. More adverse childhood experiences predict more violent conflict tactics and fewer negotiation-based conflict tactics. Self-esteem and impulsivity mediated associations between recalled childhood experiences and conflict tactics. Further research is required to explore other predisposing factors, psychological processes, and cultural and social norms surrounding the use of violent and nonviolent intimate partner conflict resolution by young men in Sub-Saharan Africa. Violence prevention strategies and policies should explicitly link intimate partner violence prevention with prevention of violence against boys. Interventions should recognize men who perpetrate intimate partner violence are more likely victims of violent childhoods than men who do not perpetrate intimate partner violence. Promoting collective self-esteem and reducing impulsivity among young men may reduce violence against women.

Come Together to Decrease Depression: Women's mental health, social capital, and participation in a Kenyan combined microfinance program

BACKGROUND

Tools and systems to improve mental health have been understudied in low-resource environments, such as sub-Saharan Africa. This study explores depression amongst women participating in a community-based intervention combining savings- and lending-groups, entrepreneurial training and other skills training.

AIMS

This study aims to determine whether depression decreases with more program participation, and the extent to which social capital variables may explain these changes.

METHOD

Survey data were gathered in June 2018, within 6 months of group formation, and again in June 2019 from 400 women participants in the program. Data between 2018 and 2019 were compared using Wilcoxon rank-sum and Chi square tests. Inferential statistics included random effects regression models and general structural equation models.

RESULTS

At 1-year follow-up, depression and loneliness amongst Kenyan women (n = 400) participating in the program had decreased. Social capital remained higher within groups than within the broader community, and mediated the association between program participation and decreased depression.

CONCLUSIONS

Findings suggest this novel, community-based intervention has the potential to benefit mental health. Future research, including a randomised control trial, is required to establish (1) the extent of the program's benefits and (2) the program's application to particular subject areas and population segments.

Rapid Development, Training, and Implementation of a Remote Health Profession's Student Volunteer Corps During the COVID-19 Pandemic

Public health in the United States has long been challenged by budget cuts and a declining workforce. The COVID-19 pandemic exposed the vulnerabilities left by years of neglecting this crucial frontline defense against emerging infectious diseases. In the early days of the pandemic, the University of Texas Medical Branch and the Galveston County Health District (GCHD) partnered to bolster Galveston County's public health response. We mobilized interprofessional teams of students and provided training to implement projects identified by GCHD as necessary for responding to the pandemic. We provided a safe outlet for students to contribute to their community by creating remote volunteer opportunities when students faced displacement from clinical rotations and in-person didactics converted to virtual formats. As students gradually returned to clinical rotations and didactic demands increased, it became necessary to expand volunteer efforts beyond what had initially been mostly hand-selected student teams. We have passed the initial emergency response phase of COVID-19 in Galveston County and are transitioning into more long-term opportunities as COVID-19 moves from pandemic to endemic. In this case study, we describe our successes and lessons learned.

Rise in Murine Typhus in Galveston County, Texas, USA, 2018

Murine typhus, an undifferentiated febrile illness caused by Rickettsia typhi, is increasing in prevalence and distribution throughout Texas. In 2018, a total of 40 cases of murine typhus were reported in Galveston County. This increase, unprecedented since the 1940s, highlights the importance of awareness by physicians and public health officials.

Come together to promote health: case study and theoretical perspectives from a Kenyan community-based program

Over the past four decades, group-based microfinance programs have spread rapidly throughout south Asia, sub-Saharan Africa and Latin America. Recent evaluations of the programs have identified social capital as a common byproduct of frequent association by members, increasing trust, belonging and normative influence. Concurrently, social capital is increasingly recognized as an important health determinant. We present an overview of a program intervention operating in Kenya that utilizes a microfinance approach to produce social capital, and seeks to leverage that social capital to promote health at three levels-the village, group, and individual. A theory of change is presented for each of these three levels, demonstrating conceptually and with program examples how social capital can be applied to promote health. Related social theories and approaches, further research and program directions are given for each of the three levels. We identify potential to improve a broad range of health outcomes through this innovative model, which requires engagement with health promotion researchers and planners in low- and middle-income countries for further refinement and validation.

Intimate Partnerships, Suicidal Ideation and Suicide-Related Hospitalization Among Young Kenyan Men

The first study focused on a three-month chart review containing information on suicide attempts (n = 34) admitted to a local mission hospital in Meru County, Kenya. The second study utilized a cross-sectional survey administered to men 18-34 years old (n = 532) residing in rural Kenya. Data posit intimate partnership discord as salient to suicide ideation and behavior. Men who reported their partner status was "divorced" had four-times the odds of reporting suicide ideation than other partnership states, an association significantly mediated by loneliness. Violent conflict tactics predicted suicidal ideation, mediated by loneliness and decreased marital satisfaction.

Mental health and childhood memories among rural Kenyan men: Considering the role of spirituality in life-course pathways

Globally there is high morbidity due to mental illnesses, necessitating research on positive mental health and new models of mental health promotion. This study investigates the mediating role of spirituality to known pathways between childhood social exposures and adult mental health outcomes-hope, meaning in life and depression among young Kenyan men. Using the "religion as attachment" framework, we investigate whether childhood attachment conditions predict lower scores of daily spiritual experiences, and whether this pathway mediates associations between childhood attachment conditions and current depression, meaning in life, and hope. Spirituality significantly mediated associations between childhood attachments and adult mental health.

Community perceptions of home environments that lead children & youth to the street in semi-rural Kenya

Research with street-involved children and youth (SICY) in Sub-Saharan Africa over the past three decades has established a complex web of both micro and macro-level factors that simultaneously "push" and "pull" children and youth to the street. There is still little research with adult family and community members in communities from which SICY originate. Forty men and women from five semi-rural villages in Meru County, Kenya participated in a Rapid Rural Appraisal utilizing a fishbone diagram to explore main and underlying reasons for why children may be or may feel unwelcome in the home and thus migrate to the street. Responses were analyzed in terms of ecological levels, child or parent perspective, and the push/pull framework. Overall, community members identified families and households experiencing stress and lacking the necessary resources to successfully adjust and adapt. Four ecological levels of influence were proposed as main reasons, with parent and caregiver factors mentioned most often, followed by household factors, children's intrapersonal factors, and interpersonal (family) factors. Community and environmental level factors were also proposed as underlying factors. Analysis by gender revealed that both men and women emphasized push factors over pull factors, though men proposed more pull factors (from peers and street life) than women did. Men placed more responsibility on the children than women did, citing children's negative behaviors, dissatisfaction with home, and a desire for independence and work/income. Women, in contrast, emphasized children's feelings of being unloved and the experience of harsh punishment or abuse from caregivers. Findings suggest that interventions to reduce street involvement should support economically, medically, and psychologically vulnerable families and households through comprehensive family strengthening programs that build financial capacity, improve parenting and communication skills, and promote education over child work and labor.

Subjective Social Standing and Conflict Tactics Among Young Kenyan Men

Efforts to reduce intimate partner violence in sub-Saharan Africa generally approach the issue through the lens of women's empowerment. These efforts include foci on women's relative power in the relationship, educational background, and earning potential. The social status of men has largely been ignored, reducing the potential to involve them in efforts to demote intimate partner violence. In this study we consider whether a man's perceived social status predicts conflict tactics, and whether these tactics are mediated by loneliness and collective self-esteem from a community-based sample in semi-rural Kenya (n = 263). We find that men who reported lower perceived social status also reported significantly more frequent violent conflicts with their intimate partners. This association was significantly, and completely, mediated by lower collective self-esteem and higher loneliness. There was no direct association between subjective social status and negotiation-based conflict tactics, although there was an indirect association. Men with higher perceived social status reported higher collective self-esteem, and men with higher collective self-esteem reported more negotiation-based conflict tactics. These findings inform efforts to reduce intimate partner violence by involving men, showing potential to reduce violence by building self-esteem among men-particularly those with lower perceived social status.

The use of pill counts as a facilitator of adherence with antiretroviral therapy in resource limited settings

BACKGROUND

Pill counts are often used to measure adherence to ART, but there is little data on how they affect adherence. We previously showed a bivariate relationship between clinicians counting pills and adherence in patients receiving HIV care in Kenya. We present a secondary analysis of the relationship between numbers of pill counts and clinical outcomes in resource limited settings.

METHODS

Patients initiating ART at Kijabe Hospital were monitored for the number of discretionary pill counts performed by their clinician in the first 6 months of ART. Subjects were followed for at least 1 year after enrollment. The number of clinician pill counts was correlated to ART adherence. The primary endpoints were time to treatment failure, defined as a detectable HIV-1 viral load, death; or loss to follow-up.

RESULTS

Clinician pill counts were done at 68% of clinic visits for 304 subjects. There was a positive correlation between the number of clinician pill counts and ART adherence (r = 0.21, p <0.001). Patients were divided into 3 groups (0 counts, 1 to 3 counts, 4 to 7 counts) and exhibited adherence of 76%, 84%, and 92%, respectively (p = 0.004). Time to treatment failure for these groups was 220 days, 438 days, and 497 days (P<0.01), respectively. Time to virologic failure in living patients remaining in the cohort was longer in those with more pill count (P =0.02). Multi-variate analysis adjusting for co-variates affecting time to treatment failure found that that clinician pill counts were associated with a decreased risk of treatment failure (HR = 0.69, p =0.04).

CONCLUSIONS

The number of clinician pill count performed was independently associated with better adherence and a decreased risk of treatment failure. The use of clinician pill counts should be further studied as an adherence promoter through a randomized clinical trial.

The clinical impact of continuing to prescribe antiretroviral therapy in patients with advanced AIDS who manifest no virologic or immunologic benefit

Introduction

Despite the efficacy and tolerability of modern antiretroviral therapy (ART), many patients with advanced AIDS prescribed these regimens do not achieve viral suppression or immune reconstitution as a result of poor adherence, drug resistance, or both. The clinical outcomes of continued ART prescription for such patients have not been well characterized.

Methods

We examined the causes and predictors of all-cause mortality, AIDS-defining conditions, and serious non-AIDS-defining events among a cohort of participants in a clinical trial of pre-emptive therapy for CMV disease. We focused on participants who, despite ART had failed to achieve virologic suppression and substantive immune reconstitution.

Results

233 ART-receiving participants entered with a median baseline CD4+ T cell count of 30/mm³ and plasma HIV RNA of 5 log₁₀ copies/mL. During a median 96 weeks of follow-up, 24.0% died (a mortality rate of 10.7/100 patient-years); 27.5% reported a new AIDS-defining condition, and 22.3% a new serious non-AIDS event. Of the deaths, 42.8% were due to an AIDS-defining condition, 44.6% were due to a non-AIDS-defining condition, and 12.5% were of unknown etiology. Decreased risk of mortality was associated with baseline CD4+ T cell count ≥25/mm³ and lower baseline HIV RNA.

Conclusions

Among patients with advanced AIDS prescribed modern ART who achieve neither virologic suppression nor immune reconstitution, crude mortality percentages appear to be lower than reported in cohorts of patients studied a decade earlier. Also, in contrast to the era before modern ART became available, nearly half of the deaths in our modern-era study were caused by serious non-AIDS-defining events. Even among the most advanced AIDS patients who were not obtaining apparent immunologic and virologic benefit from ART, continued prescription of these medications appears to alter the natural history of AIDS—improving survival and shifting the causes of death from AIDS- to non-AIDS-defining conditions.

A model for reduced HIV-1 viral load monitoring in resource-limited settings

BACKGROUND

Viral load monitoring of antiretroviral therapy in low-income countries is rarely used because of high costs. Reducing the frequency of monitoring may make it financially feasible.

METHODS

We modeled three testing schemes: reduced viral load monitoring (RVLM) with CD4 count at baseline and viral load testing at 6, 36, and 60 months; United States Department of Health and Human Services (US DHHS) Treatment Guidelines; and World Health Organization (WHO) Guidelines using a cohort of 313 HIV-infected patients using Kaplan-Meier analysis.

RESULTS

Median time to detection of antiretroviral therapy (ART) failure using RVLM was 147 days; using US DHHS, it was 115 days; and using WHO guidelines, it was 1110 days. Median time for the development of first thymidine analog mutation was 594 days. The cost of RVLM was significantly lower than US DHHS.

CONCLUSIONS

RVLM detected failure significantly sooner than CD4 count monitoring alone at a lower cost than US DHHS monitoring. RVLM is a potentially effective method of monitoring ART in resource-limited settings.

An observational cohort comparison of facilitators of retention in care and adherence to anti-eetroviral therapy at an HIV treatment center in Kenya

BACKGROUND

Most HIV treatment programs in resource-limited settings utilize multiple facilitators of adherence and retention in care but there is little data on the efficacy of these methods. We performed an observational cohort analysis of a treatment program in Kenya to assess which program components promote adherence and retention in HIV care in East Africa.

METHODS

Patients initiating ART at A.I.C. Kijabe Hospital were prospectively enrolled in an observational study. Kijabe has an intensive program to promote adherence and retention in care during the first 6 months of ART that incorporates the following facilitators: home visits by community health workers, community based support groups, pharmacy counseling, and unannounced pill counts by clinicians. The primary endpoint was time to treatment failure, defined as a detectable HIV-1 viral load; discontinuation of ART; death; or loss to follow-up. Time to treatment failure for each facilitator was calculated using Kaplan-Meier analysis. The relative effects of the facilitators were determined by the Cox Proportional Hazards Model.

RESULTS

301 patients were enrolled. Time to treatment failure was longer in patients participating in support groups (448 days vs. 337 days, P<0.001), pharmacy counseling (480 days vs. 386 days, P = 0.002), pill counts (482 days vs. 189 days, P<0.001) and home visits (485 days vs. 426 days, P = 0.024). Better adherence was seen with support groups (89% vs. 82%, P = 0.05) and pill counts (89% vs. 75%, P = 0.02). Multivariate analysis using the Cox Model found significant reductions in risk of treatment failure associated with pill counts (HR = 0.19, P<0.001) and support groups (HR = 0.43, P = 0.003).

CONCLUSION

Unannounced pill counts by the clinician and community based support groups were associated with better long term treatment success and with better adherence.

A quality assessment tool for tuberculosis control activities in resource limited settings

Tuberculosis (TB) is a significant problem, infecting nearly 9 million new patients per year and killing about 2 million a year. The primary means with which to affect TB globally are to decrease transmission locally, mainly by effective identification, diagnosis, and treatment of infectious TB patients. Therefore, quality assurance of TB control efforts at the local level is essential. This study describes the creation of a data extraction tool for retrospective chart review based on the International Standards for TB Care, 2009 for the assessment of TB control programs located in resource limited settings. The tool was field tested at a rural mission hospital in central Kenya. Results were used by host site staff to develop a quality improvement plan. The process prompted revision of the tool to clarify questions and answers. This is a tool that can be used in resource limited settings for data collection to assess the quality of TB care and to inform the design, implementation, and further assessment of future quality improvement initiatives.

Systematic review and meta-analysis: renal safety of tenofovir disoproxil fumarate in HIV-infected patients

BACKGROUND

The efficacy of tenofovir disoproxil fumarate (TDF) as part of combination antiretroviral treatment (ART) has been demonstrated in several randomized, controlled trials. However, an increasing number of case reports suggest that TDF use may be associated with significant nephrotoxicity. Our objective was to determine the renal safety of TDF-containing ART regimens for HIV-infected individuals.

METHODS

MEDLINE, EMBASE, Global Health, Scopus, Biosis Previews, Cochrane Library, Web of Science, and existing systematic reviews were searched. Prospective studies comparing TDF-containing with non-TDF containing ART regimens were selected for inclusion. We extracted data on study characteristics, participant characteristics, therapeutic interventions, renal function, bone density, and fracture rates.

RESULTS

A total of 17 studies (including 9 randomized, controlled trials) met the selection criteria. Median sample size was 517 participants. Constituent ART regimens were diverse. There was a significantly greater loss of kidney function among the TDF recipients, compared with control subjects (mean difference in calculated creatinine clearance, 3.92 mL/min; 95% confidence interval [CI], 2.13-5.70 mL/min), as well as a greater risk of acute renal failure (risk difference, 0.7%; 95% CI, 0.2-1.2). There was no evidence that TDF use led to increased risk of severe proteinuria, hypophosphatemia, or fractures.

CONCLUSIONS

Although TDF use was associated with a statistically significant loss of renal function, the clinical magnitude of this effect was modest. Our findings do not support the need to restrict TDF use in jurisdictions where regular monitoring of renal function and serum phosphate levels is impractical.

Contemporary costs of HIV healthcare in the HAART era

BACKGROUND

The delivery of HIV healthcare historically has been expensive. The most recent national data regarding HIV healthcare costs were from 1996-1998. We provide updated estimates of expenditures for HIV management.

METHODS

We performed a cross-sectional review of medical records at 10 sites in the HIV Research Network, a consortium of high-volume HIV care providers across the United States. We assessed inpatient days, outpatient visits, and prescribed antiretroviral and opportunistic illness prophylaxis medications for 14 691 adult HIV-infected patients in primary HIV care in 2006. We estimated total care expenditures, stratified by the median CD4 cell count obtained in 2006 (≤50, 51-200, 201-350, 351-500, >500 cells/μl). Per-unit costs of care were based on Healthcare Cost and Utilization Project (HCUP) data for inpatient care, discounted average wholesale prices for medications, and Medicare physician fees for outpatient care.

RESULTS

Averaging over all CD4 strata, the mean annual total expenditures per person for HIV care in 2006 in three sites was US $19 912, with an interquartile range from US $11 045 to 22 626. Average annual per-person expenditures for care were greatest for those with CD4 cell counts 50 cell/μl or less (US $40 678) and lowest for those with CD4 cell counts more than 500 cells/μl (US $16 614). The majority of costs were attributable to medications, except for those with CD4 cell counts 50 cells/μl or less, for whom inpatient costs were highest.

CONCLUSION

HIV healthcare in the United States continues to be expensive, with the majority of expenditures attributable to medications. With improved HIV survival, costs may increase and should be monitored in the future.

Low rate of CMV end-organ disease in HIV-infected patients despite low CD4+ cell counts and CMV viremia: results of ACTG protocol A5030

PURPOSE

To describe cytomegalovirus (CMV) end-organ disease (EOD) rate in AIDS patients with low CD4+ cell count despite HAART who were enrolled in a randomized, placebo-controlled trial of preemptive valganciclovir (VGCV) to prevent CMV EOD in those with CMV viremia.

METHODS

Subjects (N = 338) were HIV-infected with CD4+ count <100 cells/mm3, plasma HIV RNA >400 copies/mL, and on stable or no HAART. All underwent plasma CMV DNA PCR testing every 8 weeks (Step 1); those with detectable CMV DNA were randomized to VGCV or placebo (Step 2).

RESULTS

Plasma CMV DNA was detected in 68 (20%), of whom 4 developed CMV EOD. During Step 1, 53 died. Of the 47 who entered Step 2 (24 VGCV, 23 placebo), CMV EOD was diagnosed in 10 (4 VGCV, 6 placebo) and 15 died (7 VGCV, 8 placebo). Of those randomized to placebo, 14% were diagnosed with CMV EOD at 12 months.

CONCLUSIONS

We observed a lower CMV EOD rate among subjects receiving HAART than predicted based on published literature. However, mortality was high in this study. Our findings suggest that preemptive anti-CMV therapy in patients with persistently low CD4+ cell counts in the current treatment era may not be warranted given the low incidence of CMV EOD and high all-cause mortality observed in this study population.

Treatment of hepatitis B with lamivudine and tenofovir in HIV/HBV-coinfected patients: factors associated with response

As therapy for human immunodeficiency virus (HIV) infection evolves, optimizing hepatitis B virus (HBV) treatment and identifying factors that impact its response in the HIV/HBV-coinfected population is critical. We identified retrospectively 45 HBV/HIV-coinfected patients with detectable HBV DNA by the Bayer VERSANT HBV 3.0 bDNA assay (limit of quantification 2000 copies/mL) at baseline and/or year 1 of therapy. Patients were divided into three groups based on the active HBV agent in their antiretroviral regimen: group 1 (n = 15) received lamivudine; group 2 (n = 10), lamivudine plus tenofovir and group 3 (n = 20), lamivudine followed by lamivudine plus tenofovir. HBV genotypes and resistance profiles were determined by the Bayer Trugene HBV 1.0 assay. More patients in group 2 achieved HBV DNA suppression below 2000 copies/mL (80%), loss of HBe antigen (HBeAg) (40%) and loss of HBeAg and gain of anti-HBe (20%) than did patients in group 1 or 3. More patients with HBV genotype A, achieved HBV DNA suppression <2000 copies/mL than did patients with non-A genotypes [74% (26/35) vs 20% (2/10)], respectively (P = 0.003). Risk for virological nonresponse was significant in those with non-A genotypes [odds ratio (OR) 11.1; 95% CI: 2.0-50], previous HIV therapy (OR 6.5; 95% CI: 1.2-35) and <90% compliance (OR 3.7; 95% CI: 0.99-14.3). Simultaneous therapy with lamivudine/tenofovir suppresses HBV DNA more effectively than lamivudine or tenofovir added to lamivudine. More patients infected with HBV genotype A responded than the non-A patients, regardless of therapeutic regimen, compliance or prior HIV therapy.

Do HIV care providers appropriately manage hepatitis B in coinfected patients treated with antiretroviral therapy?

BACKGROUND

The common occurrence of hepatitis B virus (HBV) infection in patients who carry the human immunodeficiency virus (HIV) demands that both viruses be recognized, evaluated, and treated when appropriate.

METHODS

We identified 357 HIV- and hepatitis B surface antigen-positive patients who underwent testing from 1999 to 2003; 155 patients who were new to our clinic and who initiated therapy for HIV and HBV coinfection were considered for inclusion in the study. The frequency of HIV testing (to determine HIV load and CD4+ cell count) performed during the first year of therapy was compared with the frequency of HBV measurements (to determine hepatitis B e antigen, antibody to hepatitis B e antigen, and HBV load), abdominal ultrasound examination, and measurement of levels of alpha-fetoprotein in serum.

RESULTS

HBV load data were obtained for only 16% of patients before initiation of antiretroviral therapy (ART), whereas HIV load was determined for 99% of patients before initiation of ART. The total number of HIV load measurements obtained during the first year after ART initiation was 497 (median number of HIV load measurements per patient, 3.0), compared with 85 measurements of HBV load (median number of HBV load measurements per patient, <1; P<.001). The percentage of patients who received any level of HBV monitoring (i.e., tests to determine hepatitis B e antigen, antibody to hepatitis B e antigen, and HBV load) after ART initiation increased from 7% in 1999 to 52% in 2001 (P<.001), whereas the percentage of patients who underwent HIV load testing remained at 80%-90% during the same period.

CONCLUSIONS

Health care providers treating patients with HIV infection during the period 1999-2003 infrequently monitored HBV response in coinfected patients, but they systematically monitored HIV response after ART initiation. Improved physician adherence to guidelines that better delineate HBV treatment and monitoring for patients with HIV-HBV coinfection is needed.

Abacavir sulfate/lamivudine/zidovudine fixed combination in the treatment of HIV infection

Treatment of HIV infection has typically been carried out using two nucleoside analogs and a protease inhibitor. Such regimens can be complex and have high pill burdens. Use of alternative regimens, such as triple nucleoside-based regimens, can improve adherence and decrease toxicities associated with protease inhibitor therapy. A formulation of abacavir sulfate/lamivudine/zidovudine allows a dosing schedule of one pill twice daily. The components have performed favorably compared with protease inhibitor-based regimens, such as indinavir. Compared with efavirenz-based regimens, abacavir sulfate/lamivudine/zidovudine has not performed as well. The combination is being studied as a cornerstone for induction maintenance strategies, in which switching a patient to abacavir sulfate/lamivudine/zidovudine has been associated with similar virologic outcomes as continuing with either protease inhibitor- or efavirenz-based regimens. Administration of abacavir sulfate/lamivudine/zidovudine also avoids side effects of antiretroviral therapy, such as hyperlipidemia, but its use is associated with a hypersensitivity reaction in a small number of patients. The combination of abacavir sulfate/lamivudine/zidovudine is an important part of the HIV armamentarium. Its potency and ease of administration make it worth consideration in the treatment of HIV, either by itself or in combination with other agents.

Multicenter evaluation of the Bayer ADVIA Centaur HIV 1/O/2 enhanced (EHIV) assay

BACKGROUND

It is important that serological assays detect antibodies to human immunodeficiency virus (HIV) in all infected individuals, including those infected with less prevalent, more diverse subtypes.

METHODS

Performance of the ADVIA Centaur HIV 1/O/2 Enhanced (EHIV) Assay was tested on 1344 samples from HIV-positive subjects, 6061 samples from groups at low-risk for HIV infection, and 1042 samples from groups at high-risk for HIV-1 and HIV-2 infection. Results were compared with those of an FDA-approved predicate assay.

RESULTS

The ADVIA Centaur EHIV Assay showed good precision with a diagnostic specificity of 99.9% and diagnostic sensitivity of 100%. HIV seroconversion was detected earlier in 6 panels, at the same time in 13 panels and later in only 1 of the panels when compared to the predicate assay, thereby narrowing the window period between infection and antibody detection. Of clinical significance, a blood donor sample that was indeterminate by HIV-1 Western blot and non-reactive by the predicate assay was repeatedly reactive in the ADVIA Centaur Assay and confirmed as positive by HIV-2 immunoblot.

CONCLUSIONS

The ADVIA Centaur EHIV Assay is useful as an aid in the diagnosis of individuals infected with HIV-1 and/or HIV-2.

Hospital and outpatient health services utilization among HIV-infected adults in care 2000-2002

BACKGROUND

Rapid changes in HIV epidemiology and antiretroviral therapy may have resulted in recent changes in patterns of healthcare utilization.

OBJECTIVE

The objective of this study was to examine sociodemographic and clinical correlates of inpatient and outpatient HIV-related health service utilization in a multistate sample of patients with HIV.

DESIGN

Demographic, clinical, and resource utilization data were collected from medical records for 2000, 2001, and 2002.

SETTING

This study was conducted at 11 U.S. HIV primary and specialty care sites in different geographic regions.

PATIENTS

In each year, HIV-positive patients with at least one CD4 count and any use of inpatient, outpatient, or emergency room services. Sample sizes were 13,392 in 2000, 15,211 in 2001, and 14,403 in 2002.

MAIN OUTCOME MEASURES

Main outcome measures were number of hospital admissions, total days in hospital, and number of outpatient clinic/office visits per year. Inpatient and outpatient costs were estimated by applying unit costs to numbers of inpatient days and outpatient visits.

RESULTS

Mean numbers of admissions per person per year decreased from 2000 (0.40) to 2002 (0.35), but this difference was not significant in multivariate analyses. Hospitalization rates were significantly higher among patients with greater immunosuppression, women, blacks, patients who acquired HIV through drug use, those 50 years of age and over, and those with Medicaid or Medicare. Mean annual outpatient visits decreased significantly between 2000 and 2002, from 6.06 to 5.66 visits per person per year. Whites, Hispanics, those 30 years of age and over, those on highly active antiretroviral therapy (HAART), and those with Medicaid or Medicare had significantly higher outpatient utilization. Inpatient costs per patient per month (PPPM) were estimated to be 514 dollars in 2000, 472 dollars in 2001, and 424 dollars in 2002; outpatient costs PPPM were estimated at 108 dollars in 2000, 100 dollars in 2001, and 101 dollars in 2002.

CONCLUSION

Changes in utilization over this 3-year period, although statistically significant in some cases, were not substantial. Hospitalization rates remain relatively high among minority or disadvantaged groups, suggesting persistent disparities in care. Combined inpatient and outpatient costs for patients on HAART were not significantly lower than for patients not on HAART.

Racial and Gender Disparities in Receipt of Highly Active Antiretroviral Therapy Persist in a Multistate Sample of HIV Patients in 2001

BACKGROUND

National data from the mid-1990s demonstrated that many eligible patients did not receive highly active antiretroviral therapy (HAART) and that racial and gender disparities existed in HAART receipt. We examined whether demographic disparities in the use of HAART persist in 2001 and if outpatient care is associated with HAART utilization.

METHODS

Demographic, clinical, and pharmacy utilization data were collected from 10 US HIV primary care sites in the HIV Research Network (HIVRN). Using multivariate logistic regression, we examined demographic and clinical differences associated with receipt of HAART and the association of outpatient utilization with HAART.

RESULTS

In our cohort in 2001, 84% of patients received HAART and 66% had 4 or more outpatient visits during calendar year (CY) 2001. Of those with 2 or more CD4 counts below 350 cells/mm in 2001, 91% received HAART; 82% of those with 1 CD4 test result below 350 cells/mm received HAART; and 77% of those with no CD4 counts below 350 cells/mm received HAART. Adjusting for care site in multivariate analyses, age >40 years (adjusted odds ratio [AOR] = 1.13), male gender (AOR = 1.23), Medicaid coverage (AOR = 1.16), Medicare coverage (AOR = 1.73), having 1 or more CD4 counts less than 350 cells/mm (AOR = 1.33), and having 4 or more outpatient visits in a year (OR = 1.34) were significantly associated with an increased likelihood of HAART. African Americans (odds ratio [OR] = 0.84) and those with an injection drug use risk factor (OR = 0.86) were less likely to receive HAART.

CONCLUSIONS

Although the overall prevalence of HAART has increased since the mid-1990s, demographic disparities in HAART receipt persist. Our results support attempts to increase access to care and frequency of outpatient visits for underutilizing groups as well as increased efforts to reduce persistent disparities in women, African Americans, and injection drug users (IDUs).

Racial and gender disparities in receipt of highly active antiretroviral therapy persist in a multistate sample of HIV patients in 2001

BACKGROUND

National data from the mid-1990s demonstrated that many eligible patients did not receive highly active antiretroviral therapy (HAART) and that racial and gender disparities existed in HAART receipt. We examined whether demographic disparities in the use of HAART persist in 2001 and if outpatient care is associated with HAART utilization.

METHODS

Demographic, clinical, and pharmacy utilization data were collected from 10 US HIV primary care sites in the HIV Research Network (HIVRN). Using multivariate logistic regression, we examined demographic and clinical differences associated with receipt of HAART and the association of outpatient utilization with HAART.

RESULTS

In our cohort in 2001, 84% of patients received HAART and 66% had 4 or more outpatient visits during calendar year (CY) 2001. Of those with 2 or more CD4 counts below 350 cells/mm in 2001, 91% received HAART; 82% of those with 1 CD4 test result below 350 cells/mm received HAART; and 77% of those with no CD4 counts below 350 cells/mm received HAART. Adjusting for care site in multivariate analyses, age >40 years (adjusted odds ratio [AOR] = 1.13), male gender (AOR = 1.23), Medicaid coverage (AOR = 1.16), Medicare coverage (AOR = 1.73), having 1 or more CD4 counts less than 350 cells/mm (AOR = 1.33), and having 4 or more outpatient visits in a year (OR = 1.34) were significantly associated with an increased likelihood of HAART. African Americans (odds ratio [OR] = 0.84) and those with an injection drug use risk factor (OR = 0.86) were less likely to receive HAART.

CONCLUSIONS

Although the overall prevalence of HAART has increased since the mid-1990s, demographic disparities in HAART receipt persist. Our results support attempts to increase access to care and frequency of outpatient visits for underutilizing groups as well as increased efforts to reduce persistent disparities in women, African Americans, and injection drug users (IDUs).

Comparison of symptoms of influenza A with abacavir-associated hypersensitivity reaction

Differentiation between abacavir hypersensitivity and viral respiratory infections is problematic. Fifteen cases of abacavir hypersensitivity were matched to 30 controls with culture proven influenza A with no abacavir exposure. Rash was associated with hypersensitivity (odds ratio [OR] = 13.1, P = 0.02) as was the presence of nausea (OR = 30, P < 0.001), vomiting (OR = 17.1, P = 0.001) or diarrhoea (OR = 22, P < 0.001). The number of gastrointestinal symptoms was also predictive of hypersensitivity reaction (P < 0.001). Respiratory symptoms (cough, sore throat, or dyspnoea) were not associated with abacavir hypersensitivity (OR = 0.08, P = 0.001). Multivariate analysis confirmed the following associations for abacavir hypersensitivity: the number of gastrointestinal symptoms (OR = 8.6, P = 0.0032), cough (OR = 0.039, P = 0.02) and rash (OR = 16.9, P = 0.07). Abacavir hypersensitivity is strongly associated with gastrointestinal (GI) symptoms. Cough without GI symptoms is associated with influenza.

Comparison of nevirapine- and efavirenz-containing antiretroviral regimens in antiretroviral-naïve patients: a cohort study

OBJECTIVE

Efavirenz (EFV) was superior to nevirapine (NVP) in two recent cohort studies; but data from clinical trials suggest that three studies are needed to validate cohort results. We performed a cohort analysis comparing time to treatment failure and change in plasma HIV-1 RNA from baseline in antiretroviral therapy (ART)-naïve individuals treated with NVP- or EFV-containing regimens.

METHOD

A cohort analysis of three observational databases (N = >10,000 patients) found 1,078 ART-naïve individuals treated with NVP-containing (n = 523) or EFV-containing (n = 555) regimens. Patients were evenly matched and received at least three antiretroviral agents. The primary endpoint was time to treatment failure defined as a rebound in plasma HIV-1 RNA > 400 copies/mL. Other endpoints were change in plasma HIV-1 RNA from baseline and percent with plasma HIV-1 RNA <400 copies/mL over time. Potential confounding variables were analyzed using the Cox proportional hazards model.

RESULTS

Compared to EFV, NVP patients had a shorter time to treatment failure (307 days vs. 589 days; p <.001), less decrease in plasma HIV-1 RNA (-0.51 log vs. -1.32 log; p <.001), and fewer patients with plasma HIV-1 RNA < 400 copies/ mL (45% vs. 51%; p <.001). Significant factors for failure were baseline CD4 count (per 100 cell increase) or viral load (per log increase), treatment center, and year of entry (p <.05 for all comparisons). Race, gender, and background nucleoside use were insignificant factors. Multivariate analysis that included significant factors for failure demonstrated improved relative hazard with EFV compared to NVP (odds ratio = 0.50, p <.001).

CONCLUSION

EFV-containing antiretroviral regimens were associated with superior clinical outcome, as measured by time to treatment failure. Results are commensurate with other large cohort studies comparing EFV and NVP.

Trizivir

Treatment of HIV infection has typically been carried out using two nucleoside analogues and a protease inhibitor (PI). Such regimens can be complex and have high pill burdens. Use of alternative regimens, such as triple nucleoside based regimens, can improve adherence and decrease toxicities associated with PI therapy. Trizivir is a combination tablet of zidovudine, lamivudine and abacavir. This formulation allows a dosing schedule of one pill twice-daily. The components of have performed favourably compared to PI-based regimens, such as indinavir. However, in one study the individual components of Trizivir did not suppress HIV-1 viral replication as well as the PI-based regimen in a subset of patients with very high HIV-1 plasma RNA. Trizivir also avoids side effects of antiretroviral therapy, such as hyperlipidaemia, but its use is associated with a hypersensitivity reaction in a small number of patients. Trizivir is an important part of the HIV armamentarium. The potency and ease of administration of Trizivir make it worth consideration in HIV therapy, either by itself or in combination with other agents.

An anti-CD45RO immunotoxin kills latently infected human immunodeficiency virus (HIV) CD4 T cells in the blood of HIV-positive persons

Highly active antiretroviral therapy has decreased the morbidity and mortality of human immunodeficiency virus (HIV) infection, but latently infected cells remain for prolonged periods. CD4(+) CD45RO(+) T cells are a major latent virus reservoir in HIV-infected persons. Replication-competent, latently HIV-infected T cells can be generated in vitro by infecting peripheral blood mononuclear cells with HIV and then eliminating the HIV-producing cells with an anti-CD25 immunotoxin (IT). The CD25(-) latently infected cells then can be eliminated with an anti-CD45RO IT. This study determined whether this IT also could kill latently infected CD4 T cells from HIV-infected persons with or without detectable plasma viremia. The results show that ex vivo treatment of cells from HIV-positive persons by anti-CD45RO IT reduces the frequency of both productively and latently infected cells. In contrast, CD4(+) CD45RA(+) naive T cells and a proportion of CD4(+) CD45RO(lo) memory T cells are spared.

Role of sequencing in therapy selection

The goals of sequencing antiretroviral agents are to preserve as many treatment options as possible, minimize drug toxicity, and prolong suppression of HIV. There are numerous options for sequencing antiretroviral agents when treatment fails. The most common reasons for treatment failure are the emergence of resistance and poor adherence. Data indicate that protease inhibitor therapy enhanced by ritonavir may delay the development of resistance longer than nonboosted protease inhibitor therapy. The results of using efavirenz or abacavir to simplify protease inhibitor treatment regimens for HIV-suppressed patients are promising. Although resistance to nonnucleoside reverse transcriptase inhibitors is a serious problem, sequencing them after zidovudine or abacavir therapy may be effective because of the hypersusceptibility to nonnucleoside reverse transcriptase inhibitors exhibited by viral populations in many nucleoside reverse transcriptase inhibitor-experienced patients. New antiretrovirals with greater tolerability, higher genetic barriers, and less cross-resistance than existing agents are needed to achieve further dramatic advances in treating HIV infection.

Evidence for increased T cell turnover and decreased thymic output in HIV infection

The effects of HIV infection upon the thymus and peripheral T cell turnover have been implicated in the pathogenesis of AIDS. In this study, we investigated whether decreased thymic output, increased T cell proliferation, or both can occur in HIV infection. We measured peripheral blood levels of TCR rearrangement excision circles (TREC) and parameters of cell proliferation, including Ki67 expression and ex vivo bromodeoxyuridine incorporation in 22 individuals with early untreated HIV disease and in 15 HIV-infected individuals undergoing temporary interruption of therapy. We found an inverse association between increased T cell proliferation with rapid viral recrudescence and a decrease in TREC levels. However, during early HIV infection, we found that CD45RO-CD27high (naive) CD4+ T cell proliferation did not increase, despite a loss of TREC within naive CD4+ T cells. A possible explanation for this is that decreased thymic output occurs in HIV-infected humans. This suggests that the loss of TREC during HIV infection can arise from a combination of increased T cell proliferation and decreased thymic output, and that both mechanisms can contribute to the perturbations in T cell homeostasis that underlie the pathogenesis of AIDS.

Protease inhibitor therapy is associated with markedly prolonged time to relapse and improved survival in AIDS patients with cytomegalovirus retinitis

Prior to the use of highly active antiretroviral therapy (HAART), cytomegalovirus retinitis (CMV-R) in AIDS patients was characterized by multiple relapses and decreased survival. Recent data suggest that CMV-R in patients treated with HAART may remain relapse-free for long periods. We performed a study of the effects of HIV protease inhibitors (PIs) on the incidence of relapse and time to death in AIDS patients with CMV-R treated with anti-CMV therapy. Medical records of all AIDS patients with CMV-R at Parkland Memorial Health and Hospital System treated with anti-CMV agents were reviewed for date of diagnosis of CMV-R, date of CMV-R relapse, type and duration of anti-CMV therapy, and duration of PI therapy. Relapse rates in subjects treated with PIs were compared with the relapse rates in those who were not treated with PIs. The primary endpoint was the time to relapse and death as determined by Kaplan-Meier analysis. Multivariate analysis was performed by Cox proportional hazard model. One hundred and nine cases of CMV-R were identified in 75 patients. Median follow-up time was 247 days (range 31-1818 days). There were 0.54 relapses per 1000 patient days in the group treated with PIs compared with 1.83 relapses per 1000 patient days in the non-PI treatment group (relative risk [RR]=0.29, P<0.01). Time to relapse was increased in the PI treatment group compared with the non-PI treatment group (endpoint not reached vs 182 days, P<0.001, log-rank). Similarly, the time to relapse or death was increased in the PI group compared with the non-PI group (543 days vs 103 days, P<0.001, log-rank). Multivariate analysis utilizing the Cox proportional hazards model demonstrated that only PI therapy but not anti-CMV therapy was associated with decreased risk of CMV-R relapse or death. Only 3 patients with an undetectable HIV viral load and one patient with a CD4 count >120 cells/microl had a relapse. We conclude that patients with CMV-R treated with HAART containing a PI have increased time to relapse and have prolonged survival.

Treatment of patients with refractory giardiasis

Giardia lamblia is one of the most common parasitic infections. Although standard treatments are usually curative, some immunocompromised patients, including patients with acquired immunodeficiency syndrome as well as healthy patients, have giardiasis that is refractory to recommended regimens. We report our experience with 6 patients with giardiasis, for whom therapy with a combination of quinacrine and metronidazole resulted in cures for 5 of the 6 patients.

Long-term impact of highly active antiretroviral therapy on HIV-related health care costs

CONTEXT

Highly active antiretroviral therapy (HAART) is associated with decreased opportunistic infections, hospitalization, and HIV-related health care costs over relatively short periods of time. We have previously demonstrated that decreases in total HIV cost are proportional to penetration of protease inhibitor therapy in our clinic.

OBJECTIVE

To determine the effects of HAART on HIV health care use and costs over 44 months.

SETTING

A comprehensive HIV service within a Veterans Affairs Medical Center.

DESIGN

A cost-effectiveness analysis of HAART.

MAIN OUTCOME MEASUREMENTS

The mean monthly number of hospital days, infectious diseases clinic visits, emergency room visits, non-HIV-related outpatient visits, inpatient costs, and antiretroviral treatment costs per patient were determined by dividing these during the period from January 1995 through June 1998 into four intervals. Viral load tests were available from October 1996. Cost-effectiveness of HAART was evaluated by determining the costs of achieving an undetectable viral load over time.

RESULTS

Mean monthly hospitalization and associated inpatient costs decreased and remained low 2 years after the introduction of protease inhibitors (37 hospital days per 100 patients). Total cost decreased from $1905 per patient per month during the first quarter to $1090 per patient per month in the third quarter but increased to $1391 per patient per month in the fourth quarter. Antiretroviral treatment costs increased throughout the entire observation period from $79 per patient per month to $518 per patient per month. Hospitalization costs decreased from $1275 per patient per month in the first quarter to less than $500 per patient per month in each of the third and fourth quarters. The percentage of patients with a viral load <500 copies/mL increased from 21% in October 1996 to 47% in June of 1997 (p =.014). The cost of achieving an undetectable viral load decreased from $4438 per patient per month to $2669 per patient per month, but this trend did not reach statistical significance (p =.18).

CONCLUSIONS

After an initial decrease, there was an increase in the total monthly cost of caring for HIV patients. Cost increases were primarily due to antiretroviral treatment costs, but these costs were offset by a marked decrease in inpatient-related costs. Increases in costs were not related to antiretroviral treatment failures as measured by the proportion of patients with low or undetectable viral loads. The cost of achieving an undetectable viral load remained stable despite increases in the cost of procuring antiretroviral agents.

Abacavir-lamivudine-zidovudine vs indinavir-lamivudine-zidovudine in antiretroviral-naive HIV-infected adults: A randomized equivalence trial

CONTEXT

Abacavir, a nucleoside analogue, has demonstrated suppression of human immunodeficiency virus (HIV) replication alone and in combination therapy. However, the role of abacavir in a triple nucleoside combination regimen has not been evaluated against a standard protease inhibitor-containing regimen for initial antiretroviral treatment.

OBJECTIVE

To evaluate antiretroviral equivalence and safety of an abacavir-lamivudine-zidovudine regimen compared with an indinavir-lamivudine-zidovudine regimen.

DESIGN AND SETTING

A multicenter, phase 3, randomized, double-blind trial with an enrollment period from August 1997 to June 1998, with follow-up through 48 weeks at 73 clinical research units in the United States, Canada, Australia, and Europe.

PATIENTS

Five hundred sixty-two antiretroviral-naive, HIV-infected adults with a plasma HIV RNA level of at least 10 000 copies/mL and a CD4 cell count of at least 100 x 10(6)/L.

INTERVENTIONS

Patients were stratified by baseline HIV RNA level and randomly assigned to receive a combination tablet containing 150 mg of lamivudine and 300 mg of zidovudine twice daily plus either 300 mg of abacavir twice daily and indinavir placebo or 800 mg of indinavir every 8 hours daily plus abacavir placebo. After 16 weeks, patients with confirmed HIV RNA levels greater than 400 copies/mL were eligible to continue receiving randomized treatment or receive open-label therapy.

MAIN OUTCOME MEASURE

Virologic suppression, defined as HIV RNA concentration of 400 copies/mL or less at week 48.

RESULTS

The proportion of patients who met the end point of having an HIV RNA level of 400 copies/mL or less at week 48 was equivalent in the abacavir group (51% [133/262]) and in the indinavir group (51% [136/265]) with a treatment difference of -0.6% (95% confidence interval [CI], -9% to 8%). In patients with baseline HIV RNA levels greater than 100 000 copies/mL, the proportion of patients achieving less than 50 copies/mL was greater in the indinavir group than in the abacavir group with 45% (45/100) vs 31% (30/96) and a treatment diference of -14% (95% CI, -27% to 0%). The 2 treatments were comparable with respect to their effects on CD4 cell count. There was no difference between groups in the frequency of treatment-limiting adverse events or laboratory abnormalities. One death in the abacavir group was attributed to hypersensitivity reaction, which occurred following rechallenge with abacavir, approximately 3 weeks after initiating study treatment.

CONCLUSIONS

In this study of antiretroviral-naive HIV-infected adults, the triple nucleoside regimen of abacavir-lamivudine-zidovudine was equivalent to the regimen of indinavir-lamivudine-zidovudine in achieving a plasma HIV RNA level of less than 400 copies/mL at 48 weeks.

Low-dose daily subcutaneous interleukin-2 in combination with highly active antiretroviral therapy in HIV+ patients: a randomized controlled trial

PURPOSE

Previous studies with intermittent interleukin-2 (IL-2) therapy using intermediate and high levels of IL-2 have demonstrated significant increases in the CD4 + T cell count in HIV-infected patients. Intermittent regimens are amenable to outpatient use, but severe adverse events are frequently experienced with intermediate- and high-dose levels of IL-2. Therefore in this study, the effect of daily, subcutaneous low-dose IL-2 therapy on safety and immunological endpoints was investigated to determine whether immunological benefit could be achieved without toxicity in HIV-infected patients also receiving highly active antiretroviral therapy (HAART).

METHOD

A total of 115 patients were enrolled in the trial. Fifty-six asymptomatic HIV-infected patients who had CD4 + T cell counts less than 300 cells/microL at screening and a stable HIV viral load received low-dose IL-2 (1.2 million IU [MIU]/m 2 beginning dose) once daily in conjunction with HAART (IL-2 group). Fifty-nine patients received HAART alone (control group).

RESULTS

A dramatic effect of IL-2 on the natural killer (NK) cell population was observed with mean increases of 156 cells/microL in the IL-2 group compared to 19.93 cells/microL in the control group (p <.001). Additionally, IL-2-treated patients experienced a statistically significant increase in the mean percentage of CD4 + T cells (3.52% increase) when compared to control patients (1.33% increase) (p <.001). The expanded CD4 + T cell population was primarily of the naive phenotype, with mean increases of 4.53% for the IL-2 group and 0.31% for the control group (p <.001 for between-group difference). In addition, a higher proportion of IL-2-treated patients (67%) compared to control patients (33%) achieved increases of greater than 50% in the CD4+ T cell count (p =.08). Adverse events of grade 3 or grade 4 toxicity were infrequent in the current study and were substantially lower by comparison to those in studies of intermittent dose IL-2 therapy. Also, negligible changes in the HIV viral load from baseline to final measurement were observed in both groups. A trend toward a reduced number of modifications of antiretroviral therapy was apparent in the IL-2 group when compared to control patients.

CONCLUSION

Daily, low-dose subcutaneous IL-2 therapy in conjunction with HAART is safe and well tolerated and is effective in expanding lymphocyte cell types including NK cells and naive T cells in individuals who have <300 CD4+ T cells.

A randomized, double-blind trial comparing azithromycin and clarithromycin in the treatment of disseminated Mycobacterium avium infection in patients with human immunodeficiency virus

Two hundred and forty-six patients infected with human immunodeficiency virus (HIV) who also had disseminated Mycobacterium avium complex received either azithromycin 250 mg every day, azithromycin 600 mg every day, or clarithromycin 500 mg twice a day, each combined with ethambutol, for 24 weeks. Samples drawn from patients were cultured and clinically assessed every 3 weeks up to week 12, then monthly thereafter through week 24 of double-blind therapy and every 3 months while on open-label therapy through the conclusion of the trial. The azithromycin 250 mg arm of the study was dropped after an interim analysis showed a lower rate of clearance of bacteremia. At 24 weeks of therapy, the likelihood of patients' developing 2 consecutive negative cultures (46% vs. 56%, P=.24) or 1 negative culture (59% vs. 61%, P=.80) was similar for azithromycin 600 mg (n=68) and clarithromycin (n=57), respectively. The likelihood of relapse was 39% versus 27% (P=.21) on azithromycin compared with clarithromycin, respectively. Of the 6 patients who experienced relapse, none of those randomized to receive azithromycin developed isolates resistant to macrolides, compared with 2 of 3 patients randomized to receive clarithromycin [corrected]. Mortality was similar in patients comprising each arm of the study (69% vs. 63%; hazard, 95.1% confidence interval, 1.1 [0.7, 1.7]). Azithromycin 600 mg, when given in combination with ethambutol, is an effective agent for the treatment of disseminated M. avium disease in patients infected with HIV.

Efficacy of nelfinavir in patients switched from ritonavir/saquinavir combination antiretroviral therapy

Based on available data and expert opinion, the IAS-USA treatment guidelines recommend "selective substitution" of the medication thought most likely to be causing a side effect for one that should have a different side effect profile.

PURPOSE

This study evaluates the short-term virological efficacy of selective substitution with nelfinavir-nucleoside combination therapy in individuals with plasma viral RNA below 400 copies/mL.

METHOD

This study involved a retrospective chart review at five large urban HIV Clinical practice settings and included 19 patients taking combination therapy including ritonavir with saquinavir. We performed selective substitution with a nelfinavir combination. Our main outcome measure was plasma HIV-1 RNA (Amplicor) obtained during the period between weeks 12 to 18.

RESULTS

We identified 19 HIV-1-infected individuals with evidence of viral suppression as defined by a viral load below 400 copies/mL while taking dual nucleoside reverse transcriptase inhibitors with ritonavir/saquinavir. Reasons for switching included adverse effects (37%) or preference for nelfinavir due to the possibility of a better defined salvage regimen (63%). We defined a composite viral endpoint indicative of continued viral suppression using the first 12 to 18 weeks following the medication change. We found that 73% maintained undetectable viral loads (plasma HIV RNA below 400 copies/mL) during this period.

CONCLUSION

These data suggest that any medication adjustment should be made cautiously, as there may be some potential risk in a substitution. Selective substitution of a medication that has undesirable side effects or other characteristics should be considered when the possible risks of the loss of viral suppression are outweighed by the potential benefits of that substitution.