Leona E. Markson

The relationship of clinic experience with advanced HIV and survival of women with AIDS

Objective:Hospital and physician experience have been linked to improved outcomes for persons with HIV. Because many HIV-infected patients receive care in clinics, we studied clinic HIV experience and survival for women with AIDS. Design:Retrospective cohort study of women with AIDS whose dominant sources of care were clinics. Clinic HIV experience was estimated as the cumulative number of Medicaid enrollees with advanced HIV who used a particular clinic as their dominant provider up to the year of the patients AIDS diagnosis: low experience (< 20 patients), medium (20–99 patients), high (≥ 100 patients). Proportional hazards models examined relationships between experience and survival. Setting:A total of 117 New York State clinics. Patients:A total of 887 New York State Medicaid-enrolled women diagnosed with AIDS in 1989–1992. Main outcome measure:Survival after AIDS diagnosis. Results:In later study years (1991–1992), patients in high experience clinics had an approximately 50% reduction in the relative hazard of death (0.53; 95% confidence interval, 0.35–0.82) compared with patients in low experience clinics. Adjusting for demographic and clinical variables, 71% of patients in high experience clinics were alive 21 months after diagnosis compared with 53% in low experience clinics. Experience and survival were not significantly associated in the early study years (1989–1990). Conclusions:In more recent years, women with AIDS receiving care in high experience clinics survived longer after AIDS diagnosis than those in low experience clinics, providing further evidence of a relationship between provider HIV experience and outcomes.

AIDS SPECIALIST VERSUS GENERALIST AMBULATORY CARE FOR ADVANCED HIV INFECTION AND IMPACT ON HOSPITAL USE

We examined patterns of ambulatory care in the year before diagnosis of acquired immune deficiency syndrome (AIDS) for 5,720 persons infected with human immunodeficiency virus (HIV) who were continuously enrolled in the New York State Medicaid program and diagnosed in 1984–90. For 3,175 persons followed ≥ 6 months after AIDS, we also examined the change between the year before AIDS diagnosis and the 6 months afterward in the predominant provider who was seen most frequently and at least twice. Approximately 75% of the population had a predominant provider identified. Of this group, 43% of the patients had a generalist as their predominant provider before AIDS diagnosis, falling to only 25% after diagnosis. The proportion with an AIDS specialist predominant provider increased from 22% before AIDS diagnosis to 39% afterward (P < 0.001). Patients with a generalist predominant provider before AIDS diagnosis had higher odds of switching providers and of hospitalization after AIDS diagnosis than patients with an AIDS specialist predominant provider. If generalists are to be encouraged to manage patients with advanced HIV disease, a better understanding of factors contributing to these outcomes is needed.

Cigarette smoking and maternal-child HIV transmission.

We investigated the association of cigarette smoking with maternal-child HIV transmission, adjusting for illicit drug use, maternal clinical status, and delivery factors. Vital statistics birth data were linked to the New York State Medicaid HIV/AIDS Research Database for HIV-infected women delivering a liveborn singleton from 1988 through 1990. Follow-up of these children was accomplished by Medicaid data > or = 2 years after birth, and their HIV status was ascertained by a clinically based classification. The adjusted relative risk or hazard (RH) of transmission for maternal factors was determined from Cox models. The overall transmission was 24.5% for the 901 maternal-child pairs. Smokers comprised 40% of women with data on smoking (n = 768); their transmission rate was 31% versus 22% for nonsmokers (p = 0.02). In the entire cohort, the adjusted RH of transmission for smokers was 1.45 (95% confidence interval [CI] 1.07-1.96); among women with advanced HIV, the adjusted RH was even higher (RH = 1.71; 95% CI 1.14-2.58). Users of cocaine (15% of the cohort) or of mixed or unspecified illicit drugs (28%) had higher transmission rates in unadjusted analysis (33%, p = 0.06 and 31%, p = 0.06 respectively); after adjustment for smoking and other maternal factors, neither cocaine (RH = 1.04 (95% CI 0.66-1.63)) nor mixed nor unspecified drug use (RH = 1.13 (95% CI = 0.75-1.70)) was significantly associated with transmission. Our data document an association of cigarette smoking during pregnancy with an increased risk of maternal-child HIV transmission that can be added to the growing list of complications caused by cigarette smoking.

Health care delivery, zidovudine use, and survival of women and men with AIDS.

SummaryThe aim of this study was to define predictors of survival for women and men after AIDS diagnosis. We examined health care delivery and drug therapy in the year before AIDS diagnosis for continuously enrolled New York State Medicaid beneficiaries with AIDS in 1988–1990. We examined the association of these factors with survival after AIDS diagnosis. Of 1,077 women and 1,871 men, 60% of both gender groups were drug users. In both risk groups, women had more outpatient visits than men but were equally likely to visit an AIDS specialist. In those who were not drug users, men were twice as likely as women to receive either zidovudine or Pneumocystis carinii pneumonia prophylaxis. No difference appeared among drug users. Survival after AIDS diagnosis was similar by gender for those who were not drug users (RR = 1.09; 95% CI = 0.90–1.33). In drug users, women had a slightly lower risk of death than men (RR = 0.84; 95% CI = 0.72–0.98). Risk of death after AIDS diagnosis was higher for persons starting zidovudine earlier in both risk groups. Among drug users, women received more ambulatory care and survived slightly longer than men. Among those who were not drug users, survival was similar by gender even after adjusting for differences in care.

Repeated emergency department use by HIV-infected persons: Effect of clinic accessibility and expertise in HIV care

Repeated emergency department (ED) visits by HIV-infected persons may signify poor access to care or treatment from inexperienced ambulatory providers. We examined features of 157 clinics following 6820 HIV-infected patients and associations with repeated (> or =2) ED visits by these patients in the year before their first AIDS diagnosis. Patient clinical and health care data came from 1987-1992 New York State (NYS) Medicaid files and clinic data came from interviews of clinic directors. The HIV/AIDS experience of each study patients clinic was measured as the annual number of Medicaid enrollees newly diagnosed with AIDS who were contemporaneously followed by the patients clinic. Repeated ED use was observed for 24%. The adjusted odds ratio (AOR) of repeated ED visits was reduced for patients in clinics with a physician on-call (0.77; 95% confidence interval [CI] = 0.65, 0.92), evening or weekend clinic hours (0.77; 95% CI = 0.64, 0.93), or >50 AIDS patients/year in 1987-1988 (0.56; 95% CI = 0.44, 0.71) versus fewer patients in those years. Patients in clinics with more than one feature promoting accessibility or HIV expertise had a greater reduction in their AOR of repeated ED use. HIV-infected patients in clinics with greater accessibility and HIV expertise rely less on the ED for care.

Prenatal care and birth outcomes of a cohort of HIV-infected women

Adequate prenatal care has been linked to improved birth outcomes in general populations but has not been assessed in HIV-infected women. We examined longitudinal claims files and vital statistics records for women in the New York State Medicaid HIV/AIDS data base delivering a singleton from 1985 through 1990. Adequacy of the self-reported number of prenatal visits was assessed by the Kessner index. In logistics models, we estimated the association of prenatal care, illicit drug use, and other maternal characteristics with three outcomes; low birth weight, preterm birth, and small-for-gestational-age. Of 2,254 singletons delivered by this HIV-infected cohort, 28% were low birth weight, 23% were preterm birth, and 20% were small for gestational age. Two-thirds had inadequate prenatal care. Non-drug users had 57 and 26% lower adjusted odds of low birth weight and preterm delivery than drug users. The adjusted odds of low birth weight and preterm birth for women with an adequate number of prenatal visits were, respectively, 48 and 21% lower than for women with inadequate care. Adequate prenatal care was also associated with a 43% reduction in the odds of small-for-gestational-age. An adequate number of prenatal visits by women in this HIV cohort was associated with a significant reduction in all three adverse birth outcomes, but most had inadequate prenatal care. These data support strengthening efforts to bring pregnant, HIV-infected women into care.

Survival experience of 789 children with the acquired immunodeficiency syndrome

To define predictors of survival we studied longitudinal histories of 789 New York State Medicaid-enrolled children diagnosed with acquired immunodeficiency syndrome (AIDS) from 1983 to 1989 and followed through 1990. Median survival times for 3 severity groups of AIDS-defining conditions were 66, 48 and 9 months. In a proportional hazards model, the relative risk of death for the most vs. least severe group was 3.33 (95% confidence interval, 2.53, 4.37) and the relative risk for children < 6 months old at diagnosis vs. older children was 1.81 (95% confidence interval, 1.41, 2.34). We increased our ability to predict death by using a 4-category severity index that assesses both the AIDS-defining diagnosis and clinical complications within 3 months of diagnosis (relative risk, 5.27; 95% confidence interval, 3.16, 8.78 for most vs. least severe). These analyses offer new clinical severity measures and reveal that, regardless of the AIDS-defining diagnosis, children with AIDS who are < 6 months old have a poor prognosis.

Estimation of survival after AIDS diagnosis: CD4 T lymphocyte count versus clinical severity.

We compared the relative contribution to estimating survival after AIDS diagnosis of a clinical severity measure, the Severity Index for Adults with AIDS (SIAA), and laboratory values at AIDS diagnosis that are often used prognostically. Three SIAA categories were defined from the first AIDS-defining condition and the most severe complication within 3 months. We studied 421 Italian patients surviving > or = 3 months after AIDS diagnosis. Survival curves for laboratory measures grouped by quartile showed poorest survival for CD4 count <100/microliter, hemoglobin <8 g/dl, total lymphocyte count <400/microliter, and albumin <3 g/dl. Adjusting for demographics and zidovudine therapy, the estimated hazard of death was 2.4 (95% CI, 1.6-3.5) for CD4 counts <100/microliter versus higher counts and 4.9 (95% CI, 3.0- 7.8) for the most versus the least severe SIAA category. SIAA offered greater prognostic discrimination than CD4 count at AIDS diagnosis.

Prenatal care of HIV-infected women : analysis of a large New York state cohort

We examined the effect of methadone treatment, duration of Medicaid enrollment during pregnancy, and other maternal characteristics on receipt of prenatal care by 2,254 women infected with human immunodeficiency virus (HIV) delivering a singleton in New York state from 1985 through 1990. Data were obtained from the New York State Medicaid HIV/AIDS Research Data Base and vital statistics records. Adequacy of the number of prenatal visits reported by the mother on vital statistics records was assessed with use of the Kessner Index, which adjusts for gestational age at delivery. Too few visits were reported by 65% of the study population. Illicit drug users had higher odds of having too few visits [1.64, 95% confidence interval (CI) 1.24-2.17] than methadone-treated women but the odds were similar for non-drug users and methadone-treated women (0.79, 95% CI 0.60-1.25). Women with brief Medicaid enrollment (< or = 25% of pregnancy) had 45% higher odds of having too few visits than did longer enrollees. Treatment for drug addiction and longer Medicaid enrollment during pregnancy may offer important interventions to increase prenatal care of HIV-infected women. Approaches to increase prenatal care of HIV-infected women are especially important given trials showing a reduction in vertical transmission from zidovudine treatment during pregnancy.

A population-based comparison of the clinical course of children and adults with AIDS

ObjectiveTo examine the association of clinical complications and age at diagnosis with survival for a cohort of children and adults with AIDS. DesignA population-based analysis of 734 children and 5584 adults diagnosed with AIDS from 1985 to 1990 in New York State. ResultsThe initial AIDS-defining diagnoses for 68% of children were lymphoid interstitial pneumonitis or infections specified in the Centers for Disease Control and Preventions (CDC) pediatric AIDS case definition but not the CDCs 1987 adult AIDS case definition. Of opportunistic infections in both case definitions, Pneumocystis carinii pneumonia (PCP) was the most common initial AIDS diagnosis, occurring in 53% of adults, 47% of children aged < 6 months at diagnosis (n = 122) and 14% aged ≥6 months at diagnosis (n = 612). Median survival after AIDS diagnosis was 62 months for all children compared with 11 months for adults. For children initially diagnosed with conditions only in the pediatric case definition, median survival ranged from 27 to 62 months compared with less than 12 months for children and adults with PCP. Compared with children aged 6–54 months, the estimated hazards of death for younger and older children were 2.06 [95% confidence interval (Cl), 1.48–2.86] and 1.54 (95% Cl, 1.10–2.16), respectively. ConclusionChildren survived significantly longer than adults after AIDS diagnosis, but their survival varied by age at diagnosis. Differences in the types of common initial AIDS-defining diagnoses appear to contribute to the observed differences in survival.