Jonathan Shuter

HIV-infected patients receiving lopinavir/ritonavir-based antiretroviral therapy achieve high rates of virologic suppression despite adherence rates less than 95%

Background:The observation that extremely high levels of medication adherence are required to achieve complete virologic suppression is based largely on studies of treatment-experienced patients receiving HIV protease inhibitor (PI)-based therapy without ritonavir boosting. This study aims to define the level of adherence needed to achieve virologic suppression in patients receiving boosted PI-based highly active antiretroviral therapy (HAART) with lopinavir/ritonavir. Methods:HIV-infected adults receiving a regimen containing lopinavir/ritonavir were recruited into a prospective, observational study of the relation between adherence to lopinavir/ritonavir and virologic outcomes. Adherence was measured using the Medication Event Monitoring System (MEMS; Aardex, Union City, CA). HIV-1 viral load (VL) was measured at week 24. Results:The final study population contained 64 subjects. Eighty percent had AIDS, 97% received lopinavir/ritonavir before enrollment, and most had more than 7 years of HAART experience. Mean adherence overall was 73%. Eighty percent and 59% achieved a VL <400 copies/mL and a VL <75 copies/mL, respectively. Mean adherence was 75% in those achieving a VL <75 copies/mL. High rates of virologic suppression were observed in all adherence quartiles, including the lowest quartile (range of adherence: 23.5%-53.3%). Conclusions:Moderate levels of adherence can lead to virologic suppression in most patients taking lopinavir/ritonavir-based HAART.

Factors associated with unrecognized HIV-1 infection in an inner-city emergency department

STUDY OBJECTIVE To determine the prevalence of and risk factors associated with unrecognized HIV-1 infection among medical patients presenting to an inner-city emergency department. METHODS We conducted anonymous HIV-1 testing in subjects interviewed for risk behaviors and knowledge of HIV status at an inner-city ED in the Bronx, New York. Our subjects were consecutive adult medical patients in noncritical condition (N = 1,744) who were evaluated by three physicians providing primary emergency care. Each patient was given a structured interview for demographic characteristics, risk behaviors, and knowledge of HIV status. Excess serum, drawn for clinical purposes, was linked without identifiers to responses and tested for antibodies to HIV-1. In subjects who denied HIV infection, we tested associations with seropositivity using univariate analyses and logistic-regression techniques (multivariate). RESULTS Of the 1,744 patients interviewed, 656 (37.6%) reported HIV risk behaviors. Of 970 tested for HIV-1 antibodies, 125 (12.9%) were seropositive. The prevalence of HIV-1 infection among those who denied known infection was 4.0% (35 of 875). In the multivariate model, independent predictors of unrecognized HIV-1 infection were age 35 to 44 years, crack cocaine use, history of syphilis, and ED diagnosis of an infection not necessarily related to HIV infection. Unrecognized HIV-1 infection was more likely among patients admitted to the hospital, but 21 of the 35 with unrecognized infection (60%) were not admitted and in 9(25.7%) no risk factors were identified. CONCLUSION More than one third of patients who visited one inner-city ED acknowledged HIV risk behaviors. One quarter of patients with unrecognized HIV-1 infection reported no identifiable risk factors. Easily accessible HIV counseling and testing should be considered in EDs in areas serving persons at risk for HIV infection.

A randomized controlled trial of a tailored group smoking cessation intervention for HIV-infected smokers

Background:More than half of the persons living with human immunodeficiency virus (HIV; PLWH) in the US smoke cigarettes, and tobacco use is responsible for considerable morbidity and mortality in this group. Little is known about the efficacy of tobacco treatment strategies in PLWH. Design:Randomized controlled trial comparing Positively Smoke Free (PSF), an intensive group-therapy intervention targeting HIV-infected smokers, to standard care. Methods:A cohort of 145 PLWH smokers, recruited from an HIV-care center in the Bronx, New York, were randomized 1:1 into the PSF program or standard care. All were offered a 3-month supply of nicotine replacement therapy. PSF is an 8-session program tailored to address the needs and concerns of HIV-infected smokers. The sessions were cofacilitated by a graduate student and an HIV-infected peer. The primary outcome was biochemically confirmed, 7-day point-prevalence abstinence at 3 months. Results:In the intention-to-treat analysis, PSF condition subjects had nearly double the quit rate of controls (19.2% vs. 9.7%, P = 0.11). In the complete case, as-treated analysis, assignment to PSF was associated with increased odds of quitting (odds ratioadj 3.55, 95% confidence interval 1.04 to 12.0). Latino ethnicity and lower loneliness score were predictive of abstinence. The subjects in the PSF condition exhibited significant decreases in daily cigarette consumption and significant increases in self-efficacy and in motivation to quit. Attendance of ≥7 sessions was associated with higher quit rates. Conclusions:These findings suggest a positive effect of PSF on cessation rates in PLWH smokers. Loneliness and self-efficacy are influential factors in the smoking behaviors of PLWH.

Rates of and risk factors for Trichomoniasis among pregnant inmates in New York city

Background: Trichomonas vaginalis is a common pathogen that is associated with adverse pregnancy outcomes and may serve as a cofactor in human immunodeficiency virus (HIV) transmission. Goal: To define the epidemiology of trichomoniasis in a population of newly incarcerated pregnant women in New York City. Study Design: Prospective study of 213 pregnant prisoners attending prenatal clinic. Patients participated in an interview regarding sexual and drug‐related behaviors, and underwent direct culture for T. vaginalis in addition to routine testing for syphilis, gonorrhea, and chlamydia. Results: The prevalence of trichomoniasis was 46.9%. On univariate analysis, there was a significant association between trichomoniasis and older age, crack use, prostitution, known HIV infection, and positive serological test for syphilis. Multivariate analysis showed a significant association of trichomoniasis with crack use and positive serological test for syphilis. Conclusions: Trichomoniasis is highly prevalent in pregnant prisoners in New York City. The extent of disease observed may justify a formal program of testing and treatment and emphasizes the urgent need for harm reduction education and expanded HIV counseling and testing services in this high‐risk population.

A comparison of factors associated with prevalent diabetes mellitus among HIV-infected antiretroviral-naive individuals versus individuals in the National Health and Nutritional Examination Survey cohort

Background:In the general population, diabetes mellitus (DM) is associated with age, minority race/ethnicity, and obesity. Among HIV-infected persons, antiretroviral therapy (ART) use and hepatitis C virus (HCV) infection have been associated with DM. This study examined DM prevalence and its predictors in ART-naive HIV-infected patients. Methods:A cross-sectional analysis of ART-naive HIV-infected adults enrolled in 3 Terry Beirn Community Programs for Clinical Research on AIDS (CPCRA) clinical trials versus adults enrolled in the National Health and Nutritional Examination Survey (NHANES). Results:The prevalence of DM in the CPCRA clinical trials versus the NHANES was 3.3% versus 4.8%. The mean body mass index (BMI) was lower in the CPCRA trials versus the NHANES (25 kg/m2 vs. 28 kg/m2). HCV was associated with DM only in univariate analyses in the CPCRA trials. In univariate and multivariate analyses, race/ethnicity, age, and BMI were associated with DM in both cohorts. Among women, age and BMI were associated with DM in both cohorts; race/ethnicity was associated with DM only in the NHANES. HCV was predictive of DM in blacks in the CPCRA trials (P = 0.004 before adjustment for multiple comparisons) but not in the full cohort. Conclusions:Our findings did not suggest an increased prevalence of DM in ART-naive HIV-infected patients. Although there was a trend toward increased prevalence of DM in HIV-HCV-coinfected patients, dominant risk factors associated with DM among ART-naive HIV-infected adults mirrored those of the general population.

Prevalence and predictive value of Overweight in an urban HIV care clinic

Objective: To determine the prevalence and predictive value of overweight in an urban HIV clinic. Methods: Medical records of all new adult, nonpregnant registrants in 1996 in an urban HIV clinic with at least one height and weight measurement were reviewed. Body mass index (BMI) at clinic enrollment was calculated, and prevalence of overweight was thus determined. The subsequent clinical course of the overweight group was compared with that of a randomly selected group of gender‐stratified nonoverweight patients. Results: At baseline, 12.6% of men and 32.5% of women were overweight. Female gender and lack of AIDS diagnosis were independently associated with overweight. More than one half of women and 19.6% of men were overweight at some point during the study. Providers were more likely to properly acknowledge underweight than overweight. Among patients without AIDS, there was a trend toward slower disease progression and lower viral load in overweight patients, despite similar baseline CD4+ lymphocyte counts and similar time to initiation of highly active antiretroviral therapy. In multivariate proportional hazards analyses, lower baseline BMI and falling BMI during follow‐up were independently predictive of progression to AIDS. Conclusions: Overweight was a common and underrecognized finding, particularly among women. Overweight patients may progress more slowly to AIDS than nonoverweight patients.

Cigarette smoking behaviors and beliefs in persons living with HIV/AIDS.

OBJECTIVE To measure biopsychosocial domains related to tobacco use in persons living with HIV/AIDS (PLWHAs). METHODS Cross-sectional interview study of 60 PLWHA smokers randomly selected from an HIV clinic. RESULTS Participants averaged 14.4 cigarettes daily. Sixty-five percent were moderately or highly nicotine dependent, and most were motivated to quit. Substance use and depression were very common. Most reported that smoking helped them cope with depression, anxiety, and anger. Twenty-seven percent thought (mistakenly) that smoking raised their T-cell counts and/or helped fight infections. Referrals to quitlines or cessation programs were uncommon. CONCLUSIONS Smoking among PLWHAs is a challenging problem requiring targeted intervention strategies.

Provider beliefs and practices relating to tobacco use in patients living with HIV/AIDS: A national survey

The entire online HIV Medical Association US registry was invited to complete a questionnaire regarding beliefs and practices related to smoking in persons living with HIV/AIDS (PLWHAs). 363/486 returned completed questionnaires. Respondents from 43 states reported caring for 76,570 PLWHAs. Only 22.9% had ever received formal tobacco treatment training. Respondents generally agreed that smoking is an important issue in PLWHAs, but reported low levels of cessation-promoting activities. Providers with larger patient panels, “primarily HIV” practices, and formal cessation training had higher questionnaire scores, indicating stronger beliefs in the harms of smoking, benefits of quitting, and effectiveness of cessation strategies.

Feasibility and preliminary efficacy of a web-based smoking cessation intervention for HIV-infected smokers: A randomized controlled trial

Objective:To evaluate the feasibility and preliminary efficacy of a Web-based tobacco treatment for persons living with HIV (PLWH). Design:Prospective, randomized controlled trial. Setting:HIV-care center in the Bronx, New York. Subjects:Eligibility criteria included HIV infection, current tobacco usage, interest in quitting, and access to a computer with internet. One hundred thirty-eight subjects enrolled, and 134 completed the study. Intervention:Positively Smoke Free on the Web (PSFW), an 8-session, 7-week targeted tobacco treatment program for PLWH, was compared with standard care (brief advice to quit and self-help brochure). All subjects were offered nicotine patches. Main Outcome Measures:The main feasibility outcomes were number of sessions logged into, number of Web pages visited, number of interactive clicks, and total time logged in. The main efficacy outcome was biochemically verified, 7-day point prevalence abstinence 3 months after intervention. Results:PSFW subjects logged into a mean of 5.5 of 8 sessions and 26.2 of 41 pages. They executed a mean of 10 interactive clicks during a mean total of 59.8 minutes logged in. Most required reminder phone calls to complete the sessions. Educational level, anxiety score, and home access of the Web site were associated with Web site usage. Ten percent of the PSFW group vs. 4.3% of controls achieved the abstinence end point. Among those who completed all 8 sessions, 17.9% were abstinent, and among women completers, 30.8% were abstinent. Conclusions:Web-based treatment is a feasible strategy for PLWH smokers, and preliminary findings suggest therapeutic efficacy.

Rates of and factors associated with self-reported prior HIV testing among adult medical patients in an inner city emergency department in the Bronx, New York City

We studied the rates of and factors associated with self-reported prior human immunodeficiency virus (HIV) testing in adult patients visiting an emergency department (ED) in the Bronx, New York City. A total of 1,744 consecutive noncritical adult medical emergency patients responded to a standardized interview administered by ED physicians. The interview included questions pertaining to demographic characteristics, prior HIV testing, and HIV risk behaviors. On multivariate analysis, female gender, younger age, history of weight loss, injecting drug use (IDU), syphilis, and genital herpes were all associated with increased reported prior testing rates. Race (i.e., black race) was an independent predictor of increased rates among male subjects; comparatively low rates were reported by patients with a first language other than English, patients lacking medical insurance, and highly sexually active, nonblack men. Increased HIV testing rates were reported by subjects with recognized HIV risk behaviors in a New York City ED population; however, substantial proportions of subjects at risk had not been tested. Programs of HIV testing and counseling need to include older, uninsured, and non-English-speaking segments of the population who engage in high-risk behaviors.