Joan Duggan

Use of Complementary and Alternative Therapies in HIV-Infected Patients

The use of complementary and alternative medicine (CAM) therapies is widespread in many chronic illnesses, including human immunodeficiency virus (HIV) infection. The objective of this study was to determine the impact of increasingly effective antiretroviral therapy on the use of CAM in an HIV-positive patient population. A written survey was given to 191 HIV-positive outpatients. Participation was voluntary and anonymous. One hundred twenty-eight patients (67%) used CAM at some time to control HIV and 76 (40%) of the patients were currently using CAM. The major forms of CAM used were exercise (43%), lifestyle changes (38%), dietary supplements (37%), counseling (27%), herbal medications (26%), megavitamins (24%), and prayer therapy (24%). One hundred forty-one patients (74%) used a protease inhibitor medication, 28 (15%) used a protease inhibitor sparing regime, and 22 (11%) had no current or prior antiretroviral use. Eighty-two (43%) patients indicated that their doctor knew they used CAM and 56 patients (29%) received their information about CAM from a doctor or other health care professional. Of 128 patients who used CAM, 90 (70%) felt CAM improved their quality of life. Income of

Religion and HIV: a review of the literature and clinical implications

15,000 or more per year and discontinuation of medications by patients for any reason in the past were the best predicators of CAM use for patients in general and also those on protease inhibitor therapy. CD(4) count, educational status, year of HIV diagnosis, and martial status were not effective predictors of CAM use. Use of CAM remains widespread among patients with HIV infection even with the availability of effective, yet noncurative antiretroviral therapy and does not correlate with type of antiretroviral therapy used or clinical status.

Inverse Correlation Between Level of Professional Education and Rate of Handwashing Compliance in a Teaching Hospital

Despite substantive research documenting the connection between various religious dimensions and physical and mental health, surprisingly little attention has been given to the study of religion among individuals with the human immunodeficiency virus (HIV). Although initially considered to be a white, “gay man’s” disease, today women and ethnic minorities are subgroups that are the most severely affected by the HIV pandemic. Importantly, these disenfranchised subgroups report greater use of religion in their everyday lives. A small but growing number of studies conducted mostly within the past few years have recognized the importance of religion in the lives of individuals with HIV. In particular, research has noted the frequent use of religious coping by men and women with HIV to deal with the loss of their loved ones to AIDS, to overcome their sense of guilt and shame in engaging in risky behaviors, and to find a renewed sense of purpose in life. However, clinical interventions with persons with HIV have largely neglected religiousness and spirituality as resources for treatment and, to date, few spirituality-based interventions exist that can be empirically evaluated. In this paper, we review the literature on religious coping among individuals with HIV and outline a clinical intervention that incorporates religious issues relevant to this population. We first provide an overview of religious coping.

HIV/AIDS knowledge among female migrant farm workers in the midwest.

OBJECTIVE To evaluate educational level as a contributing factor in handwashing compliance. DESIGN Observation of hand washing opportunities was performed for approximately 12 weeks before an announced Joint Commission on Accreditation of Healthcare Organizations (JCAHO) visit and for approximately 10 weeks after the visit. Trained observers recorded the date, time, and location of the observation; the type of healthcare worker or hospital employee observed; and the type of hand hygiene opportunity observed. SETTING University of Toledo Medical Center, a 319-bed teaching hospital. RESULTS A total of 2,373 observations were performed. The rate of hand washing compliance among nurses was 91.3% overall. Medical attending physicians had the lowest observed rate of compliance (72.4%; P<.001). Nurses showed statistically significant improvement in their rate of hand hygiene compliance after the JCAHO visit (P = .001), but no improvement was seen for attending physicians (P = .117). The compliance rate in the surgical intensive care unit was more than 90%, greater than that in other hospital units (P = .001). Statistically, the compliance rate was better during the first part of the week (Monday, Tuesday, and Wednesday) than during the latter part of the week (Thursday and Friday) (P = .002), and the compliance rate was better during the 3 PM-11 PM shift, compared with the 7 AM-3 PM shift (P<.001). When evaluated by logistic regression analysis, non-physician healthcare worker status and observation after the JCAHO accreditation visit were associated with an increased rate of hand hygiene compliance. CONCLUSION An inverse correlation existed between the level of professional educational and the rate of compliance. Future research initiatives may need to address the different motivating factors for hand hygiene among nurses and physicians to increase compliance.

ts1 and LP-BM5: A Comparison of Two Murine Retrovirus Models for HIV

The rate of HIV infection in the migrant farm worker community is 10 times the national average. A survey was conducted of 106 female migrant farm workers in rural Northwest Ohio to assess HIV knowledge. The average participants age was 28.7 years, 78 spoke Spanish, and 47 had an ≤8th- grade education. Fifty-six women received their information on HIV/AIDS from television. Eighty-seven women identified sexual contact as the major source of HIV transmission and 54 women identified the combination of sex, use of needles, and blood contact as the important routes. Sixty-nine women identified both homosexual and heterosexual intercourse as risk factors. Only 58 women identified perinatal infection as a route of HIV transmission and 59 women knew that treatment was available to prevent perinatal transmission. Although the majority of women had a good general knowledge of HIV transmission, further prevention education on perinatal transmission is needed among this population.

Adherence to antiretroviral therapy: a survey of factors associated with medication usage

The ts1 murine leukemia virus produces an immunodeficiency state in mice that parallels human immunodeficiency virus (HIV) infection in humans. Other murine leukemia viruses, such as LP-BM5 used in the murine acquired immune deficiency virus (MAIDS) model, have been studied extensively as a small animal model for HIV research, but lack many key similarities to HIV. Mice infected with ts1, however, utilize CD4 target cells for infection, undergo neuronal loss and demyelination, and develop clinical immunodeficiency. These features make this retrovirus in many ways an ideal candidate for a small animal model for HIV research. In this review article, the early development, the molecular and clinical pathogenesis of both the ts1 mutant of the Moloney murine leukemia virus and LP-BM5 are examined. Based on an extensive evaluation of the literature on LP-BM5 and ts1, it is concluded that the ts1 virus may serve as a better animal model to human retrovirus infection.

Intensivist supervision of resident-placed central venous catheters decreases the incidence of catheter-related blood stream infections

Abstract The use of highly active antiretroviral therapy (HAART) has decreased morbidity and mortality for people living with HIV/AIDS, but adherence to HAART is a critical factor in successful treatment. Adherence to medication is a complex and poorly understood behavior. A survey was undertaken to evaluate subjective correlates of adherence and non-adherence based on previously distilled themes from a qualitative study of adherence. A 60-question survey was completed by patients in the outpatient clinic setting regarding demographics, CD4 cell count, viral load, adherence, and screening questions about medication usage and attitudes toward HIV. Ninety-eight adherent and 34 non-adherent patients completed the survey. After logistic regression analysis, several questions appeared to be the main predictors of non-adherence: Have you ever thought of having HIV as a “punishment?” Do you feel that your medicines are hard to take? Do you believe the medicines for HIV that you take are working for you? These questions may be helpful in the development of a clinically useful screening tool to assess patients at risk for non-adherence.

Clinical Outcomes Associated with Concomitant Use of Atazanavir and Proton Pump Inhibitors

Catheter-related blood stream infections (CRBSI) cause significant morbidity and mortality. A retrospective study of a performance improvement project in our teaching hospitals surgical intensive care unit (SICU) showed that intensivist supervision was important in reinforcing maximal sterile barriers (MSB) use during the placement of a central venous catheter (CVC) in the prevention of CRBSI. A historical control period, 1 January 2001–31 December 2003, was established for comparison. From 1 January 2003–31 December 2007, MSB use for central venous line placement was mandated for all operators. However, in 2003 there was no intensivist supervision of CVC placements in the SICU. The use of MSB alone did not cause a significant change in the CRBSI rate in the first year of the project, but close supervision by an intensivist in years 2004–2007, in conjunction with MSB use, demonstrated a significant drop in the CRBSI rate when compared to the years before intensivist supervision (2001–2003), p < .0001. A time series analysis comparing monthly rates of CRBSI (2001–2007) also revealed a significant downward trend, p = .028. Additionally, in the first year of the mandated MSB use (2003), 85 independently observed resident-placed CVCs demonstrated that breaks in sterile technique (34/85), as compared those placements that had no breaks in technique (51/85), had more CRBSI, 6/34 (17.6%) vs. 1/51 (1.9%), p < .01. Interventions to reduce CRBSI in our SICU needed emphasis on adequate supervision of trainees in CVC placement, in addition to use of MSB, to effect lower CRBSI rates.

Retroviral gene insertion in breast milk mediated lymphomagenesis.

Background: Pharmacokinetic studies have shown that the concomitant use of atazanavir and proton pump inhibitors (PPIs) decreases atazanavir plasma concentrations. Data describing clinical outcomes associated with this drug interaction are limited. Objective: To describe the clinical outcomes, in terms of viral load (VL) suppression, associated with the concurrent use of ritonavir-boosted or unboosted atazanavir and PPIs. Methods: A retrospective chart review of 301 HIV-positive adults attending an Ohio infectious diseases clinic was performed to identify patients prescribed atazanavir, with or without ritonavir, and a PPI. The primary outcome was achievement/maintenance of VL less than 400 copies/mL for 2 or more months during concomitant atazanavir and PPI therapies. Data collected included VL and CD4+ cell count at initiation of coadministered atazanavir and PPIs, genotype/phenotype, prior protease inhibitor experience, length of concurrent atazanavir/PPI therapy, and adherence. Results: Twelve patients met inclusion criteria. PPIs and dosing regimens varied among subjects. Five of the subjects had a VL less than 400 copies/mL at initiation of atazanavir, with or without ritonavir, which was maintained during concurrent atazanavir and PPI therapy. Four additional subjects initiated protease inhibitor treatment with a VL greater than 400 copies/mL and achieved an undetectable VL while on concurrent PPI therapy. Duration of concurrent therapy ranged from 4 to 23 months in these 9 subjects. Of the 3 patients not maintaining a VL less than 400 copies/mL, 1 achieved that level at 4 months, and all 3 of these subjects showed atazanavir susceptibility during therapy per genotype resistance testing. Subsequently, decreased atazanavir susceptibility was reported in 1 of the 3 patients after 18 months of therapy. Patients not achieving an undetectable VL had known adherence issues. Conclusions: In this case series, 9 of 12 subjects achieved successful virologic outcomes while receiving concurrent atazanavir and PPIs in a real-world environment. In our experience, the interaction between atazanavir and once-daily PPIs is not clinically significant for adherent patients. Concurrent use of these medications could be considered in patients with limited treatment options.

A Small Animal Model for Mother-to-Fetus Transmission of ts1, a Murine Retrovirus

We have demonstrated breast milk transmitted MoMuLV-ts1 retrovirus infection and subsequent lymphoma development in offspring of uninfected mothers suckled by infected surrogate mothers. Additionally, we have shown that the lymphoma development occurs as a result of viral gene integration into host genome. A total of 146 pups from Balb/C mice were divided into 5 groups; one control and 4 experimental. All offspring suckled from surrogate infected or control mothers, except one group of infected pups left with their biological mothers. Thirteen of 91 infected pups developed lymphoma. Inverse-PCR, DNA cloning, and quantitative real-time PCR (qRT-PCR) were used to study the virus integration sites (VIS) and alterations in gene expression. VIS were randomly distributed throughout the genome. The majority of insertion sites were found in chromosomes 10, 12 and 13. A total of 209 proviral genomic insertion sites were located with 52 intragenic and 157 intergenic sites. We have identified 29 target genes. Four genes including Tacc3, Aurka, Gfi1 and Ahi1 showed the maximum upregulation of mRNA expression. These four genes can be considered as candidate genes based on their association with cancer. Upregulation of these genes may be involved in this type of lymphoma development. This model provides an important opportunity to gain insight into the relationship of viral gene insertion into host genome and development of lymphoma via natural transmission route such as breast milk.