J. Bryan Page

High risk of HIV-related mortality is associated with selenium deficiency

To determine the independent contribution of specific immunologic and nutritional factors on survival in HIV-1 disease, CD4 cell count, antiretroviral treatment, plasma levels of vitamins A, E, B6, and B12 and minerals selenium and zinc were considered in relation to relative risk for HIV-related mortality. Immune parameters and nutrients known to affect immune function were evaluated at 6-month intervals in 125 HIV-1-seropositive drug-using men and women in Miami, FL, over 3.5 years. A total of 21 of the HIV-1-infected participants died of HIV-related causes during the 3.5-year longitudinal study. Subclinical malnutrition (i.e., overly low levels of prealbumin, relative risk [RR] = 4.01, p < 0.007), deficiency of vitamin A (RR = 3.23, p < 0.03), vitamin B12 deficiency (RR = 8.33, p < 0.009), zinc deficiency (RR = 2.29.1, p < 0.04), and selenium deficiency (RR = 19.9, p < 0.0001) over time, but not zidovudine treatment, were shown to each be associated with HIV-1-related mortality independent of CD4 cell counts <200/mm3 at baseline, and CD4 counts over time. When all factors that could affect survival, including CD4 counts <200/mm3 at baseline, CD4 levels over time, and nutrient deficiencies were considered jointly, only CD4 counts over time (RR = 0.69, p < 0.04) and selenium deficiency (RR = 10.8, p < 0.002) were significantly associated with mortality. These results indicate that selenium deficiency is an independent predictor of survival for those with HIV-1 infection.

The association between cigarette smoking and drug abuse in the United States

Abstract Cigarette smoking has been identified as an independent risk factor for many human diseases. However, the association between cigarette smoking and illegal drug use has not been thoroughly investigated. We have analyzed the 1994 National Household Survey on Drug Abuse to clarify whether cigarette smoking has any effect on the initiation of illegal drug use. Data from 17,809 respondents completing the 1994 “new” (1994-B) questionnaire were analyzed. Logistic regression analyses were performed with the use of statistical package SU-DAAN, taking into consideration the multistage sampling design. The results show that those who had smoked cigarettes were far more likely to use cocaine (OR = 7.5; 95% CI: 5.7-9.9), heroin (OR = 16.0; 95% CI: 6.8-37.9), crack (OR = 13.9; 95% CI: 7.9-24.5) and marijuana (OR = 7.3; 95% CI:6.2-8.7). The associations are consistent across age-strata and remain after adjusting for race and gender. This study suggests that cigarette smoking may be a gateway drug to illegal drug use.

Rapid Assessment of the HIV/AIDS Crisis in Racial and Ethnic Minority Communities: An Approach for Timely Community Interventions

OBJECTIVES The US Department of Health and Human Services, in collaboration with the Congressional Black Caucus, created a new initiative to address the disproportionate ongoing HIV/AIDS crisis in racial/ethnic minority populations. METHODS This initiative included deploying technical assistance teams through the Office of HIV/AIDS Policy. The teams introduced rapid assessment and response methodologies and trained minority communities in their use. RESULTS The first 3 eligible cities (Detroit, Miami, and Philadelphia) focused assessments in small geographic areas, using multiple methodologies to obtain data. CONCLUSIONS Data from the first 3 eligible cities provided critical information about changing the dynamics of the HIV/AIDS epidemic at the local level, including program and policy changes and infrastructure redeployment targeted at the most serious social and environmental conditions.

Randomized, Controlled Clinical Trial of Zinc Supplementation to Prevent Immunological Failure in HIV-Infected Adults

BACKGROUND Adequate zinc is critical for immune function; however, zinc deficiency occurs in >50% of human immunodeficiency virus (HIV)-infected adults. We examined the safety and efficacy of long-term zinc supplementation in relation to HIV disease progression. METHODS A prospective, randomized, controlled clinical trial was conducted involving 231 HIV-infected adults with low plasma zinc levels (<0.75 mg/L), who were randomly assigned to receive zinc (12 mg of elemental zinc for women and 15 mg for men) or placebo for 18 months. The primary end point was immunological failure. HIV viral load and CD4(+) cell count were determined every 6 months. Questionnaires, pill counts, and plasma zinc and C-reactive protein levels were used to monitor adherence to study supplements and antiretroviral therapy. Intent-to-treat analysis used multiple-event analysis, treating CD4(+) cell count <200 cells/mm(3) as a recurrent immunological failure event. Cox proportional hazard models and the general-linear model were used to analyze morbidity and mortality data. RESULTS Zinc supplementation for 18 months reduced 4-fold the likelihood of immunological failure, controlling for age, sex, food insecurity, baseline CD4(+) cell count, viral load, and antiretroviral therapy (relative rate, 0.24; 95% confidence interval, 0.10-0.56; P<.002). Viral load indicated poor control with antiretroviral therapy but was not affected by zinc supplementation. Zinc supplementation also reduced the rate of diarrhea by more than half (odds ratio, 0.4; 95% confidence interval, 0.183-0.981; P=.019), compared with placebo. There was no significant difference in mortality between the 2 groups. CONCLUSIONS This study demonstrated that long-term (18-month) zinc supplementation at nutritional levels delayed immunological failure and decreased diarrhea over time. This evidence supports the use of zinc supplementation as an adjunct therapy for HIV-infected adult cohorts with poor viral control. Trial registration. ClinicalTrials.gov identifier: NCT00149552.

HIV-Related Wasting in HIV-Infected Drug Users in the Era of Highly Active Antiretroviral Therapy

BACKGROUND A decrease in the rate of human immunodeficiency virus (HIV) infection-related wasting has been reported in the era of highly active antiretroviral therapy (HAART). We investigated this concern in a hard-to-reach population of HIV-infected drug users in Miami, Florida. METHODS After informed consent was obtained, 119 HIV-infected drug users were administered questionnaires involving demographic, medical history, and food-security information. Blood samples were drawn for immunological and viral studies. HIV-related wasting over a period of > or =6 months was defined as a body mass index of <18.5 kg/m2, unintentional weight loss of > or =10% over 6 months, or a weight of <90% of the ideal body weight. RESULTS The prevalence of HIV-related wasting was 17.6%. A significantly higher proportion of those who experienced wasting (81%) reported that there were periods during the previous month when they went for > or =1 day without eating (i.e., food insecurity), compared with those who did not experience wasting (57%). Although a greater percentage of patients who experienced wasting were receiving HAART, their HIV RNA levels were more than twice as high (mean+/-standard deviation [SD], 166,689+/-238,002 copies/mL; median log HIV RNA level +/- SD, 10.2+/-2.7 log10 copies/mL) as those for the group that did not experience wasting (mean+/-SD, 72,156 +/- 149,080; median log HIV RNA level+/-SD, 9.2+/-2.3 log10 copies/mL). Participants who experienced wasting were more likely to be heavy alcohol drinkers and users of cocaine. In multivariate analysis that included age, sex, food security, alcohol use, cocaine use, viral load, and receipt of antiretroviral therapy, the only significant predictors of wasting were > or =1 day without eating during the previous month (odds ratio [OR], 1.96; 95% confidence interval [CI], 1.18-3.26; P=.01) and viral load (OR, 1.64; 95% CI, 1.00-2.69; P=.05). CONCLUSIONS HIV-related wasting continues to be common among HIV-infected drug users, even among HAART recipients. Food insecurity and viral load were the only independent predictors of wasting. The social and economic conditions affecting the lifestyle of HIV-infected drug users constitute a challenge for prevention and treatment of wasting.

Zinc Status in Human Immunodeficiency Virus Type 1 Infection and Illicit Drug Use

Zinc deficiency is the most prevalent micronutrient abnormality seen in human immunodeficiency virus (HIV) infection. Low levels of plasma zinc predict a 3-fold increase in HIV-related mortality, whereas normalization has been associated with significantly slower disease progression and a decrease in the rate of opportunistic infections. Studies in Miami, Florida, indicated that HIV-positive users of illicit drugs are at risk for developing zinc deficiency, at least partially because of their poor dietary intake. Zinc deficiency characterized by low plasma zinc levels over time enhances HIV-associated disease progression, and low dietary zinc intake is an independent predictor of mortality in HIV-infected drug users. The amount of zinc supplementation in HIV infection appears to be critical, because deficiency, as well as excessive dietary intake of zinc, has been linked with declining CD4 cell counts and reduced survival. More research is needed to determine the optimal zinc supplementation level in HIV-infected patients, to prevent further burden on an already compromised immune system.

Cigars, cigarillos, and youth: Emergent patterns in subcultural complexes

Abstract In order to answer questions about discrepancies in self-reported tobacco use between youth from different race/ethnic categories, the authors set out to observe and characterize tobacco use among youth in two Florida counties. Their observations and interviews led to identification of a pattern of tobacco use that had not appeared before in the literature on tobacco use, the emergent phenomenon of Black & Mild consumption, especially among African American youth. Teams of field workers conducted direct observations of tobacco use among youths between the ages of 11 and 15, recruiting them and their families into open-ended interviews to determine how youths in that age range initiate and maintain tobacco use. Observational notes and in-depth interviews (all transcribed to word processing files) provided the corpus of data on which the investigators based this study. In addition, information from additional sources, including informal interviews with store owners, rap videos, and queries in other parts of the United States, helped to verify that patterns found in Miami had appeared throughout Florida and in many other parts of the United States. Initial observations took place in the environs of one middle school in southern Miami/Dade County, but additional observations and interviews that contributed to the study took place in sites near other schools, convenience stores, shopping centers, and city streets. African American, Hispanic, and white non-Hispanic young people between 11 and 15 years of age took part in this study, only after field workers obtained informed consent from their parents. Field workers conducted observations of approximately 250 youth in various settings in two counties in Florida, Miami/Dade and Alachua. They elicited 40 in-depth interviews, including one whole family interview and four focus groups. The interviews that contributed to this paper were four in-depth sessions with young African American males recruited at the middle school where key observations took place. Field observations produced a pattern of tobacco use not characterized in the literature, in which a cigarillo called “Black & Mild” that contains between five and twelve times the nicotine of cigarettes has become the product of choice among African American and other youth. Young users of these cigarillos tend not to recognize them as tobacco and believe that they contain no nicotine. Further inquiry revealed that this pattern of smoking was widespread in various parts of the United States. Use of commercial cigarettes has become increasingly expensive, and minority youth with limited money may have sought products that deliver strong nicotine for not much money. Although more research will answer this question definitively, these results suggest that the emergence of Black & Milds and related products may help to explain patterns of response to large-scale studies of tobacco use in which African American youth report less tobacco consumption than other youth. Items on tobacco use in surveys administered among North American youth need reframing in terms of cigar smoking to reflect the cultural significance of Black & Milds and related products among African American youth.

Quality of life, symptomatology and healthcare utilization in HIV/HCV co-infected drug users in Miami

Abstract HIV/HCV co-infection is becoming one of the main causes of death in HIV+ persons. We determined quality of life, clinical symptoms and health care utilization in HIV mono-infected and HIV/HCV co-infected chronic drug users. After consenting 218 HIV+ drug users, a physical examination and questionnaires on demographics, quality of life, drugs of abuse, and healthcare utilization were completed. Blood was drawn for HCV status, CD4 cell count, HIV viral load, CBC and chemistry. HIV/HCV co-infected participants had significantly higher risk of having poorer perceived outlook and health, presented significantly more frequent depression and physical symptoms, and used significantly more healthcare services than those infected with HIV only, after adjusting for age, gender, ethnicity, CD4 cell count, and viral load. Diminished quality of life in the HIV/HCV co-infected group was explained by increased frequency of depression, physical symptoms, healthcare utilization, and poor access to HCV treatment in this population.

Culture: The missing link in health research

Culture is essential for humans to exist. Yet surprisingly little attention has been paid to identifying how culture works or developing standards to guide the application of this concept in health research. This paper describes a multidisciplinary effort to find consensus on essential elements of a definition of culture to guide researchers in studying how cultural processes influence health and health behaviors. We first highlight the lack of progress made in the health sciences to explain differences between population groups, and then identify 10 key barriers in research impeding progress in more effectively and rapidly realizing equity in health outcomes. Second, we highlight the primarily mono-cultural lens through which health behavior is currently conceptualized, third, we present a consensus definition of culture as an integrating framework, and last, we provide guidelines to more effectively operationalize the concept of culture for health research. We hope this effort will be useful to researchers, reviewers, and funders alike.

HIV-1 RNA load in needles/syringes from shooting galleries in Miami: a preliminary laboratory report

We quantified HIV-1 RNA load in rinses from needles/syringes (N/S) obtained at shooting galleries in Miami and also analyzed the rinses for antibodies for viral proteins. In rinses from 36 N/S that contained visible blood, 14 (39%) had detectable amounts of HIV-1 RNA. Numbers of copies of HIV-1 RNA ranged from the detection limit (400 copies/ml) to 268,000 copies/ml. We also detected antibodies to HIV-1 polypeptides in 34/36 (94%) of rinses from visibly contaminated N/S using Western blots specific for the HIV-1 proteins. No antibodies were detected in laboratory rinses from six visibly clean needles. The presence of HIV-1 RNA in N/S is an important indication of the risk created by N/S sharing as well as by shared paraphernalia and wash waters by injecting drug users.