Jack DeHovitz

Declining prevalence of cervicovaginal human papillomavirus infection with age is independent of other risk factors.

Background and Objectives: Human papillomavirus (HPV) infection of the female genital tract is the most common sexually transmitted disease. Although the prevalence of HPV in women without detectable cervical disease has been shown to decline with increasing age, the relationship to sexual behavior has not been investigated. Goal: To identify risk factors for, and associated with the age‐dependent decline in, genital HPV infection in women. Study Design: The prevalence of HPV was determined in a cohort of 439 sexually active inner‐city women between the ages of 18 and 50 years recruited in Brooklyn, New York. Cervicovaginal cells were collected by lavage, and HPV was detected by low‐stringent Southern blot hybridization. Results: The prevalence of HPV infection ranged from 36% in women younger than 25 years of age to 2.8% in women 45 years or older. Logistic regression analysis identified an increased risk for cervical HPV infection to be independently associated with number of sex partners in the past year (odds ratio [OR], 1.04 per yearly increase in age; 95% confidence interval [CI], 1.00 to 1.08), younger age (OR, 0.92 per year increase in age; 95% CI, 0.88 to 0.95), and not living with partner (OR, 2.28; 95% CI, 1.40 to 4.22). Conclusions: The lower prevalence of HPV infection in older women compared to younger women was found to be independent of sexual behavior. These results suggest that a biologic effect, such as HPV immunity acquired over time and with multiple exposures, may mediate the inverse relationship between age and HPV prevalence.

Antiretroviral therapy exposure and incidence of diabetes mellitus in the Women's Interagency HIV Study

Objective:To determine the incidence of diabetes mellitus (DM) in a nationally representative cohort of HIV-infected women and a comparison group of HIV-uninfected women. Design:A prospective study between October 2000 and March 2006 of 2088 participants from the Womens Interagency HIV Study who did not have evidence of DM at enrollment (1524 HIV infected and 564 HIV uninfected). Methods:Incident DM was defined as either having fasting glucose ≥ 1.26 g/l, reporting antidiabetic medication, or reporting DM diagnosis (with subsequent confirmation by fasting glucose ≥ 1.26 g/l or reported antidiabetic medication); all were assessed at semi-annual study visits. Results:DM developed in 116 HIV-infected and 36 HIV-uninfected women over 6802 person-years. HIV-infected women reporting no recent antiretroviral therapy had a DM incidence rate of 1.53/100 person-years; those reporting HAART containing a protease inhibitor (PI) had a rate of 2.50/100 person-years and those reporting non-PI-containing HAART a rate of 2.89/100 person-years. None of these rates differed from the HIV-uninfected women (1.96/100 person-years) substantially or beyond levels expected by chance. Among HIV-infected women, longer cumulative exposure to nucleoside reverse transcriptase inhibitors (NRTI) was associated with an increased risk of DM incidence compared with no NRTI exposure: relative hazard (RH) 1.81 [95% confidence interval (CI), 0.83–3.93] for > 0 to 3 years exposure and RH 2.64 (95% CI, 1.11–6.32) for > 3 years exposure. Conclusion:Longer cumulative exposure to NRTI was associated with increased DM incidence in HIV-infected women. Regular DM monitoring is advisable because NRTI form the backbone of effective antiretroviral therapy.

A longitudinal study of human papillomavirus carriage in human immunodeficiency virus-infected and human immunodeficiency virus-uninfected women.

OBJECTIVE We sought to determine the relationship of human immunodeficiency virus serostatus to carriage of oncogenic human papillomavirus. MATERIAL AND METHODS A total of 268 human immunodeficiency virus-infected and 265 human immunodeficiency virus-uninfected women were seen every 6 months, at which time they had laboratory tests performed including a CD4 count. Human papillomavirus deoxyribonucleic acid was analyzed by polymerase chain reaction. Statistical methods included Kaplan-Meier and Coxs proportional hazard models. RESULTS The prevalence at baseline of any human papillomavirus type was 73% and 43% among human immunodeficiency virus-seropositive and seronegative women, respectively (p < 0.0001) and of oncogenic types was 32.5% and 17.0% (p < 0.001). The prevalence of oncogenic human papillomavirus was higher in women with CD4 counts <200 mm3 (p < 0.001). The rate of detection of new oncogenic human papillomavirus per 100 patient years of follow-up in human immunodeficiency virus-seropositive women was almost three times higher than among human immunodeficiency virus-seronegative women (p < 0.01). The rate of loss of an oncogenic human papillomavirus was higher in the human immunodeficiency virus-seronegative women but the difference was not significant. The relative risk of a human immunodeficiency virus-infected woman who did not initially have a specific type of oncogenic human papillomavirus having one detected during follow-up was 6.6 times greater than among human immunodeficiency virus-negative women (p < 0.001). CONCLUSIONS Human immunodeficiency virus-seropositive women are more likely to have newly detectable oncogenic types of human papillomavirus at follow-up and to show persistent carriage of oncogenic types of human papillomavirus types. Among human immunodeficiency virus-infected women, those with higher CD4 counts were more likely to have a newly detected oncogenic human papillomavirus during follow-up.

C-reactive protein is an independent predictor of mortality in women with HIV-1 infection.

The relationship of C-reactive protein (CRP) to mortality was assessed in 209 HIV-1–infected women after adjusting for age, body mass index (BMI), serum albumin, CD4 cell lymphocyte count, and HIV-1 RNA. During the follow-up period of up to 5 years (median = 45 months) there were 49 deaths. CRP at study enrollment was measured using a low sensitivity assay. CRP levels were only weakly correlated (Pearson correlation coefficient r < .2) with other predictors of mortality. CRP was a powerful predictor of mortality (p < .01) after adjusting for age, BMI, serum albumin, CD4 cell lymphocytes, and HIV-1 RNA. The relative hazard associated with an elevated CRP level, independent of the covariates noted above, varied from 3.4- to 13.6-fold depending on how CRP values were grouped. CRP may be a useful and inexpensive predictor of HIV disease mortality in women.

Heterosexual transmission of hepatitis C, hepatitis B, and HIV-1 in a sample of inner city women.

Background: To clarify the role of heterosexual transmission of hepatitis C virus (HCV) and to identify associated risk factors. Goal: To compare risk factors with infection among women with HCV, HIV‐1, and hepatitis B virus (HBV). Study Design: A cross‐sectional study of the prevalence of HCV, HIV‐1, and HBV in a sample of 599 sexually active, nontransfused, inner‐city women with no evidence of intravenous drug use. Results: The prevalence of HCV was 1.6%, compared with 2.0% for HIV‐1 and 18.8% for HBV; 75% of women infected with HCV were also infected with HIV‐1 or HBV (P < 0.001). Women engaging in very high‐risk sexual behavior were 14.2 times more likely to have HCV than other women (95% CI, 1.8‐642.5). Conclusions: The epidemic of HCV may be facilitated by high‐risk sexual behavior. The relatively high prevalence of HCV suggests the need for more widespread screening among inner‐city females.

Health-related quality of life of HIV-infected women: evidence for the reliability, validity and responsiveness of the Medical Outcomes Study Short-Form 20.

The purpose of this study was to assess the reliability, validity and responsiveness of a health-related quality of life (HRQOL) instrument, the Medical Outcomes Short-Form 20-ltem General Health Survey (MOS SF-20), in a sample of women with the human immunodeficiency virus (HIV). Longitudinal data were collected on 202 HIV-infected women without AIDS who were receiving care at Kings County Hospital or SUNY Health Sciences Center, Brooklyn, New York. Internal consistency results showed acceptable reliability for the four multi-item MOS scales (role function, physical function, general health perceptions and mental health). Symptomatic patients and patients with lower Karnofsky Performance Status (KPS) ratings reported lower HRQOL than those who were asymptomatic or who had higher KPS scores. Patients who were older, unemployed or who had a history of injection drug use (IDU) also reported lower HRQOL. than those who were younger, employed or who had no drug use history. Adjusted mean scores on the MOS role and physical functioning scales proved sensitive to differences in clinical status over time. The MOS SF-20 is a reliable and valid instrument of HRQOL for women with HIV infection. Its sensitivity to differences in clinical status over time suggest that it may be useful as an HRQOL indicator for HIV/AIDS clinical trials.

Total lymphocyte count, hemoglobin, and delayed-type hypersensitivity as predictors of death and AIDS illness in HIV-1-infected women receiving highly active antiretroviral therapy.

Background:Total lymphocyte count (TLC) and hemoglobin level have been suggested as useful and inexpensive parameters to indicate need for HAART in settings in which CD4+ cell counts are unavailable. If delayed-type hypersensitivity (DTH) response predicts clinical response in persons using highly active antiretroviral therapy (HAART), it may also prove useful in resource-poor settings. Objective:To examine whether TLC, hemoglobin, and DTH response observed prior to initiation of HAART predict post-HAART clinical response. Design:Prospective cohort study. Participants:873 women in the Women’s Interagency HIV Study. Measurements:TLC, hemoglobin, CD4+ cell counts, and DTH testing using mumps, candida, and tetanus toxoid antigens, performed within 1 year prior to HAART initiation; death; self-report of initiation of HAART use and AIDS-defining illness (ADI). Results:Three different multivariate analyses were performed: 2 models that excluded CD4+ cell count and assessed TLC at either <850 or <1250 cells/μL, and 1 model that excluded TLC and included CD4+ <200 cells/μL. TLC <850, TLC <1250, CD4+ <200 cells/μL, anergy to DTH testing, hemoglobin <10.6 g/dL, and a pre-HAART report of ADI were each consistently independently associated both with death and with incident ADI. Log likelihood χ2 values suggested similar power among the 3 models in predicting both death and incident ADI. Conclusions:Pre-HAART TLC, hemoglobin level, anergy to DTH testing, and clinical disease each independently predicted morbidity and death after HAART initiation. These findings support the use of TLC to guide decision-making for HAART initiation and suggest that further study of TLC, hemoglobin level, and DTH responses as an indication to provide HAART may be useful in resource-limited settings.

High-prevalence and high-estimated incidence of HIV infection among new injecting drug users in Estonia: Need for large scale prevention programs.

OBJECTIVE To examine HIV risk behavior and HIV infection among new injectors in Tallinn, Estonia. Design and methods Data from two cross-sectional surveys of injecting drug users (IDUs) recruited from a syringe exchange program (N = 162, Study 1) or using respondent driven sampling (N = 350, Study 2). Behavioral surveys were administered; serum samples were collected for HIV testing. Subjects were categorized into new injectors (injecting < or = 3 years) and long-term injectors (injecting > 3 years). RESULTS Twenty-eight of 161 (17%, Study 1) and 73/350 (21%, Study 2) of the study subjects were new injectors. HIV infection was substantial among the newer injectors: HIV prevalence was 50% (Study 1) and 34% (Study 2), and estimated HIV incidence 31/100 PY and 21/100 PY, respectively. In Study 2, new injectors were more likely to be female and ethnic Estonian and less likely to be injecting daily compared with long-term injectors. No significant difference was found among two groups on sharing injecting equipment or reported number of sexual partners. CONCLUSIONS A continuing HIV epidemic among new injectors is of critical public health concern. Interventions to prevent initiation into injecting drug use and scaling up HIV prevention programs for IDUs in Estonia are of utmost importance.

High prevalence of blood-borne virus infections and high-risk behaviour among injecting drug users in Tallinn, Estonia.

The HIV epidemic in Estonia is rapidly expanding, and injection drug users (IDUs) are the major risk group contributing to the expansion. A convenience sample of 159 IDUs visiting syringe-exchange programmes (SEPs) was selected to quantify the association of HIV-risk behaviours and blood-borne infections. A high prevalence of HIV, hepatitis B core antibody (HBVcore), hepatitis B surface antigen (HbsAg) and hepatitis C virus antibodies (56, 85.1, 21.3, and 96.2%, respectively) was associated with high-risk injections, unsafe sexual behaviour and alcohol abuse. These findings emphasize the importance of evidence-based secondary prevention among the HIV-infected, especially given the uncertain sustainability of antiretroviral and substance abuse treatments.

The relationship of cocaine use and human immunodeficiency virus serostatus to incident sexually transmitted diseases among women

Background and Objectives: To assess the incidence of sexually transmitted diseases (STD) in a group of heterosexual women as a function of human immunodeficiency virus (HIV) serostatus and to ascertain the effect of crack cocaine use on these relationships. Study Design: At baseline, 445 HIV type 1 (HIV‐1) seronegative and 232 seropositive women were provided interviews ascertaining demographic and behavioral risk factors. All participants were tested for Chlamydia trachomatis, Neisseria gonorrhoeae, and Trichomonas vaginalis at baseline and at 6‐month intervals. Results: HIV serostatus was not related to STD incidence. Although HIV‐positive women reported more condom use than did HIV‐negative women (P < .01), only 65% reported using them consistently. Increases in the frequency of crack cocaine use, measured on a 4‐point scale, were positively associated with rates of new STDs (relative risk[RR] = 1.23, P < .01). Crack cocaine use was also associated with greater numbers of sexual partners and less consistent condom use. The relationship between HIV status and the probability of acquiring an STD was not influenced by frequency of crack use. Conclusion: Women infected with HIV or who use crack cocaine are at risk for transmitting HIV and acquiring other STDs. Whether women are infected with or at risk for HIV, programs are needed to prevent and treat crack addiction. Interventions should target high‐risk sexual practices among both female crack users and women living with HIV.