Karen Brudney

Bone mass and mineral metabolism in HIV+ postmenopausal women.

The objective of this cross-sectional study was to estimate the prevalence of and risk factors for osteoporosis in HIV+ postmenopausal women. Bone mineral density (BMD) by dual energy X-ray absorptiometry (DXA) and biochemical indices of mineral metabolism were measured in 31 Hispanic and African American HIV+ postmenopausal women. BMD was compared with 186 historical controls, matched for age, ethnicity and postmenopausal status. Mean BMD was significantly lower at the lumbar spine and total hip in the HIV+ group, as compared with controls. Prevalence of osteoporosis was higher in the HIV+ group than controls at the lumbar spine (42% vs 23%, p =0.03) and total hip (10% vs 1%, p =0.003). Among HIV+ women, time since menopause and weight were significant predictors of BMD, while duration or class of antiretroviral therapy (ART), AIDS diagnosis, nadir CD4, steroid use, and vitamin D deficiency were not. Prevalence of osteoporosis is substantially higher in HIV+ Hispanic and African-American postmenopausal women than in controls. Established osteoporosis risk factors were more important in predicting BMD than factors associated with HIV infection and ART. Long-term management of the growing female HIV population should include the evaluation for and management of osteoporosis.

Staphylococcus aureus ST398, New York City and Dominican Republic

Closely related Staphylococcus aureus strains of ST398, an animal-associated strain, were identified in samples collected from humans in northern Manhattan, New York, NY, USA, and in the Dominican Republic. A large population in northern Manhattan has close ties to the Dominican Republic, suggesting international transmission.

Patterns of geographic mobility predict barriers to engagement in HIV care and antiretroviral treatment adherence.

Migration and geographic mobility increase risk for HIV infection and may influence engagement in HIV care and adherence to antiretroviral therapy. Our goal is to use the migration-linked communities of Santo Domingo, Dominican Republic, and New York City, New York, to determine the impact of geographic mobility on HIV care engagement and adherence to treatment. In-depth interviews were conducted with HIV+Dominicans receiving antiretroviral therapy, reporting travel or migration in the past 6 months and key informants (n=45). Mobility maps, visual representations of individual migration histories, including lifetime residence(s) and all trips over the past 2 years, were generated for all HIV+ Dominicans. Data from interviews and field observation were iteratively reviewed for themes. Mobility mapping revealed five distinct mobility patterns: travel for care, work-related travel, transnational travel (nuclear family at both sites), frequent long-stay travel, and vacation. Mobility patterns, including distance, duration, and complexity, varied by motivation for travel. There were two dominant barriers to care. First, a fear of HIV-related stigma at the destination led to delays seeking care and poor adherence. Second, longer trips led to treatment interruptions due to limited medication supply (30-day maximum dictated by programs or insurers). There was a notable discordance between what patients and providers perceived as mobility-induced barriers to care and the most common barriers found in the analysis. Interventions to improve HIV care for mobile populations should consider motivation for travel and address structural barriers to engagement in care and adherence.

Global Tuberculosis: Perspectives, Prospects, and Priorities

Despite being nearly 100% curable, tuberculosis remains a major public health problem, representing the second leading cause of death from infectious diseases globally, with drug-resistant tuberculosis increasingly common. In 2012, an estimated 8.6 million people developed tuberculosis worldwide—a global incidence rate of 122 persons per 100 000 population—and 1.3 million people died. Incidence rates vary from high in southern Africa (550/100 000 population in Mozambique and Zimbabwe and 1000/100 000 population in South Africa) to fewer than 10/100 000 population in the United States, Canada, and most of Western Europe.1 Although the global prevalence of multidrug-resistant tuberculosis was estimated at 3.6% of newly diagnosed and 20.2% of previously treated patients, these rates were 20% to 35% for newly diagnosed cases and 50% to 69% for retreatment cases in the Russian Federation and some other former Soviet republics. In sub-Saharan Africa, the tuberculosis epidemic is driven by HIV through both increased reactivation of latent tuberculosis infection and the increased risk of rapid development of disease soon after exposure to Mycobacterium tuberculosis because of HIV-induced immunodeficiency. There is lower tuberculosis incidence in Asia, but because Asia’s population is so much larger than Africa’s—more than 4 billion compared with about a billion—75% of the 5 million tuberculosis cases in the 22 highest-burden countries are in Asia. In these countries, crowding, poverty, and inadequate tuberculosis treatment completion rates contribute to the epidemic.2 Despite these statistics, marked progress has occurred since the World Health Organization (WHO) declared tuberculosis a global emergency 20 years ago. In 1995, fewer than 2 million patients were successfully treated using the WHO’s Directly Observed Treatment, short course (DOTS) strategy, less than a quarter of the estimated total; by 2011, nearly 5 million patients were treated successfully with DOTS. Approximately 56 million patients have been treated successfully since 1995, preventing an estimated 22 million deaths. However, every year about 3 million people with tuberculosis are missed by health systems. Mortality rates are declining, albeit slowly, in all regions of the world. Since 1990, the death rate associated with tuberculosis has decreased 45%, from 25 persons to 14/100 000 population, although rates vary widely between countries. The greatest risk to tuberculosis control is lack of implementation of effective and currently available strategies and tools. Tuberculosis control rests on 3 fundamental principles: prompt and accurate diagnosis, effective treatment begun immediately upon diagnosis and monitored until completion, and interruption of transmission. Diagnosis Microbiological examination of sputum smears for acidfast bacilli, despite limitations, remains the mainstay of diagnosis. Newer diagnostics provide greater sensitivity, particularly among children and persons with HIV infection (whose sputum smears are often negative), and can also identify rifampin resistance. These newer tests can enhance, but not yet replace, smear microscopy because of expense and requirements for suitable infrastructure, including stable electricity supplies. Early and accurate identification of tuberculosis can result in earlier treatment and decrease transmission, but only if treatment is promptly initiated.3

Purified protein derivative testing and tuberculosis preventive therapy for HIV-infected patients in New York City.

Objective:To determine whether Centers for Disease Control and Prevention recommendations for purified protein derivative (PPD) testing and tuberculosis (TB) preventive therapy for PPD-positive patients are implemented in HIV clinics. Design:Retrospective medical chart review. Setting:Ten hospital-based HIV clinics in New York City. Participants:A total of 2397 patients with a first clinic visit in 1995. Outcome measures:PPD testing of eligible patients, and recommendation of preventive therapy and completion of regimen in PPD-positive patients. Method:Outpatient medical records were abstracted for TB history, PPD testing, TB preventive therapy, and patient demographic, social and clinical characteristics. Multivariate analyses were performed using logistic regression. Results:Of 1342 patients with an indication for a PPD test, 865 (64%) were PPD tested in the clinic and 757 (88%) returned to have it read. Factors strongly associated with PPD testing in the clinic were number of visits, same sex behavior with men, and CD4+ lymphocyte count above 200 × 106/l. Preventive therapy was recommended for 80% of newly identified PPD-positive patients and 22% of previously identified PPD-positive patients. Of 119 patients on preventive therapy in the clinic, 49 (41%) completed the regimen, 50 (42%) were lost to follow-up, and 20 (17%) discontinued therapy or their status could not be determined. Conclusion:A significant number of missed opportunities to implement TB prevention practices were identified in HIV clinics. Focused attention in HIV clinics, and increased collaboration between HIV clinics and TB control programs may be needed to increase adherence to prevention guidelines.

The Acceptability of a Self-Lavaging Device Compared to Pelvic Examination for Cervical Cancer Screening Among Low-Income Women

BACKGROUND A simpler approach to cervical cancer screening could increase coverage, thus reducing cervical cancer mortality in the United States. Self-collection of specimens for screening tests may be one such approach. The aim of this study was to assess the acceptability of a self-lavaging device (Delphi Screener(™), Scherpenzeel, The Netherlands) for cervical cancer screening. Self-lavage specimens have been shown to have equivalent sensitivity for detection of high-grade cervical intraepithelial neoplasia (CIN) when coupled with high-risk human papillomavirus (HPV) tests as clinician-collected specimens with cytologic review. METHODS Low-income women (n=198) who had recently received cervical cytologic testing in one of three participating clinics in New York City enrolled; 197 self-lavaged. Women answered open-ended and closed-ended questions on ease of use, level of comfort with the self-lavage and the pelvic examination, and future screening preference. RESULTS Ninety-six percent of women reported they were very/somewhat comfortable self-lavaging compared to 47% very/somewhat comfortable with the clinician collecting a specimen during a pelvic examination (p<0.001). The majority (79%) would prefer self-lavage the next time they need to be screened; only 8% would prefer pelvic examination by a doctor, and 14% had no preference. The main reasons for preferring self-lavage centered on convenience and comfort. CONCLUSIONS Self-lavaging was highly acceptable to women in this study. Self-collection of specimens has the potential to simplify screening and reduce logistical barriers for many women, which could increase overall coverage of cervical cancer screening.

Incidence of Diabetes Mellitus and Obesity and the Overlap of Comorbidities in HIV+ Hispanics Initiating Antiretroviral Therapy

Background Cardiovascular disease (CVD) is a leading health threat for HIV+ patients on antiretroviral therapy (ART); cardiometabolic comorbidities are key predictors of risk. Data are limited on incidence of metabolic comorbidities in HIV+ individuals initiating ART in low and middle income countries (LMICs), particularly for Hispanics. We examined incidence of diabetes and obesity in a prospective cohort of those initiating ART in the Dominican Republic. Methods Participants ≥18 years, initiating ART <90 days prior to study enrollment, were examined for incidence of impaired fasting glucose (IFG), diabetes mellitus (DM), overweight, and obesity. Fasting plasma glucose (FPG) 100-125mg/dl defined IFG; FPG ≥126 mg/dl, diagnosis per medical record, or use of hypoglycemic medication defined DM. Overweight and obesity were BMI 25–30 and ≥30kg/m2, respectively. Dyslipidemia was total cholesterol ≥240mg/dl or use of lipid-lowering medication. Framingham risk equation was used to determine ten-year CVD risk at the end of observation. Results Of 153 initiating ART, 8 (6%) had DM and 23 (16%) had IFG at baseline, 6 developed DM (28/1000 person-years follow up [PYFU]) and 46 developed IFG (329/1000 PYFU). At baseline, 24 (18%) were obese and 36 (27%) were overweight, 15 became obese (69/1000 PYFU) and 22 became overweight (163/1000 PYFU). Median observation periods for the diabetes and obesity analyses were 23.5 months and 24.3 months, respectively. Increased CVD risk (≥10% 10-year Framingham risk score) was present for 13% of the cohort; 79% of the cohort had ≥1 cardiometabolic comorbidity, 48% had ≥2, and 13% had all three. Conclusions In this Hispanic cohort in an LMIC, incidences of IFG/DM and overweight/obesity were similar to or higher than that found in high income countries, and cardiometabolic disorders affected three-quarters of those initiating ART. Care models incorporating cardiovascular risk reduction into HIV treatment programs are needed to prevent CVD-associated mortality in this vulnerable population.

CLINICAL EXPERIENCE WITH RIFAMPIN-ISONIAZID-STREPTOMYCIN-ETHAMBUTOL (RISE)-RESISTANT TUBERCULOSIS

We review demographic and clinical features of 55 patients with rifampin-isoniazid-streptomycin-ethambutol (RISE)-resistant tuberculosis in our hospital from April 1, 1991, to July 31, 1993. Fifty-one of the 55 patients (median age, 36 years) were seropositive for human immunodeficiency virus (HIV), and 49 had AIDS. Among the HIV-infected patients, the median CD4 cell count was 31/mm3. Forty-two patients died during the study period. Exogenous reinfection or superinfection with RISE-resistant tuberculosis occurred in 12 of 55 patients with a prior history of tuberculosis infection or disease. Fourteen of 55 received appropriate therapy, eight of whom became culture negative after a median of 68 days. Twelve of the 14 appropriately treated patients survived at least 6 months. When appropriately managed, even severely immunosuppressed individuals with HIV infection may have their RISE-resistant tuberculosis successfully controlled or eradicated. This infection however, remains highly lethal in the majority of patients with AIDS. Patients remain infectious for prolonged periods, even after appropriate therapy has been initiated.

La vida normal: living with HIV in Santo Domingo, Dominican Republic

Abstract In this study, we explore how individuals living with HIV in the Dominican Republic strive to live a ‘normal’ life and the consequences of this pursuit of normalcy. We conducted qualitative in-depth interviews with men (n = 20) and women (n = 20) living with HIV and receiving care at two urban clinics in Santo Domingo. We analysed the data using a combination of narrative analysis and thematic coding. We aimed to identify how fears and/or lived experiences with social rejection and HIV-related stigma and discrimination shaped participants’ abilities to maintain social relationships, be economically productive and manage HIV within the context of sexual relationships. Participants used the discourse of una vida normal (a normal life) to frame their response to HIV. This pursuit of normality was driven by the social and economic pressures of living with a chronic condition in a context of HIV-related stigma; trying to keep things ‘normal’ further added to these pressures. We argue that the normal life discourse fails to recognise the dynamic and complex nature of negotiating this condition and may also create additional burdens for individuals living with HIV that could impact their wellbeing and preventive behaviours.

Treating Our Way Out of AIDS

On June 30, 2013, the World Health Organization (WHO) released revised recommendations for the initiation of antiretroviral treatment, advising all countries to begin lifelong treatment of adults living with HIV who have 500 or fewer CD4 cells per cubic millimeter. For some population groups—pregnant women, children, people with HIV and coinfections—treatment was recommended regardless of immune status. Many felt WHO lagged behind the US public health authorities, which adopted guidelines for earlier treatment in 2011.1 Some argued that a bolder WHO would have recommended the simplest prescription: treatment of all people with HIV infection. Whereas it once was cautioned as impossible to treat our way out of the epidemic, WHO now embraces “treatment as prevention,” with massive expansion of antiretroviral drug use promoted as the surest way to vanquish AIDS. Nearly 10 million HIV-infected individuals are now newly eligible for antiretroviral treatment.