Malcolm John

Staphylococcus aureus Prosthetic Valve Endocarditis: Optimal Management and Risk Factors for Death

The mortality rate associated with Staphylococcus aureus prosthetic valve endocarditis (PVE) remains high. To identify clinical events associated with an increased risk of death among patients with S. aureus PVE and to evaluate the role of valve replacement surgery in reducing mortality, we conducted a retrospective cohort study of patients who met strict criteria for definite S. aureus PVE. The primary endpoint for the study was survival at 3 months from the date of diagnosis. S. aureus PVE was diagnosed in 33 patients. Of these, 14 (42%) died within 90 days of the diagnosis. Cardiac complications were detected in 22 (67%), and central nervous system (CNS) complications were detected in 11 (33%). A stepwise logistic regression multivariate model demonstrated that cardiac complications, but not CNS complications, were associated with increased mortality and that performing valve replacement surgery during antibiotic therapy was associated with decreased mortality. These associations were confirmed by using a Cox proportional hazards model with time-dependent covariates to control for survival bias. Performing valve replacement surgery during antimicrobial therapy will reduce the mortality among patients with S. aureus PVE, even those without evidence of cardiac complications.

Methamphetamine use, sexual activity, patient-provider communication, and medication adherence among HIV-infected patients in care, San Francisco 2004-2006.

Abstract While numerous studies examine methamphetamine use and associated risky sexual behaviors in HIV-uninfected individuals, few studies have surveyed HIV-infected individuals in the health care setting. To assess the frequency and trends of methamphetamine use, sexual activity, injection drug use, patient–provider communication, and medication adherence among HIV-infected persons in care, we administered a one-page anonymous survey in 2004 and 2006. The survey was conducted at the two University of California, San Francisco outpatient HIV clinics: at Moffitt Hospital (Moffitt), serving primarily privately insured patients, and at San Francisco General Hospital (SFGH), a county hospital serving primarily patients who are uninsured or publicly insured. In 2006, 39% of men who have sex with men (MSM), 33% of heterosexual men, and 11% of women reported methamphetamine use in the prior 12 months. Methamphetamine use was significantly associated with an increased number of sex partners among MSM and heterosexual men, and poor anti-retroviral medication adherence. Among MSM, methamphetamine use was more common at the SFGH clinic. Between 2004 and 2006, reported methamphetamine use in the last 12 months decreased among MSM at Moffitt (38 to 20%, p<0.01), but increased at SFGH (40 to 50%, p<0.05). Among methamphetamine users we found a high frequency of injection of methamphetamine, which increased at SFGH from 38 to 55%, p<0.05. Patient–provider communication regarding methamphetamine use has increased from 2004 to 2006 but no significant change has been found for providers asking patients about sexual activity. Overall, we found methamphetamine use to be common among HIV-infected patients in care, and associated with an increased number of sex partners, a high frequency of injection drug use, and poor adherence to anti-retroviral medications. These findings support the need for improved screening and clinic-based interventions to reduce and treat methamphetamine abuse and associated high risk sexual behaviors.

A Pilot Study to Engage and Counsel HIV-Positive African American Youth Via Telehealth Technology

Abstract Antiretroviral nonadherence is a strong determinant of virologic failure and is negatively correlated with survival. HIV-positive African American youth have lower antiretroviral adherence and treatment engagement than other populations. We assessed the feasibility and acceptability of a telehealth (remote videoconferencing) medication counseling intervention as an innovative approach to address these disparities. HIV-positive African American youth (18-29 years old) on antiretrovirals were enrolled in a telehealth medication counseling session, followed by a semi-structured qualitative interview to explore likes/dislikes of the format, modality, and content; potential impact on adherence; privacy issues; and interaction quality. Fourteen participants with a mean age of 24 years, who were 86% male, and had a mean self-reported adherence in the past month of 89%, were interviewed. Participants stated that they liked telehealth, would use it if offered in clinic/research settings, and indicated that their privacy was maintained. Participants described telehealth as convenient and efficient, with positive impact on their knowledge. Telehealth provided a modality to interact with providers that participants described as less intimidating than in-person visits. Telehealth is feasible and acceptable for delivering medication counseling to HIV-positive African American youth when conducted in a controlled clinical setting and may improve quality of patient-provider dialogue. Use of telehealth may lead to more disclosure of treatment difficulties, increased patient comfort, and improved health education.

Human papillomavirus infection in the oral cavity of HIV patients is not reduced by initiating antiretroviral therapy.

Objective: The incidence of human papillomavirus (HPV)-related oral malignancies is increasing among HIV-infected populations, and the prevalence of oral warts has reportedly increased among HIV patients receiving antiretroviral therapy (ART). We explored whether ART initiation among treatment-naive HIV-positive adults is followed by a change in oral HPV infection or the occurrence of oral warts. Design: Prospective, observational study. Methods: HIV-1 infected, ART-naive adults initiating ART in a clinical trial were enrolled. End points included detection of HPV DNA in throat-washes, changes in CD4+ T-cell count and HIV RNA, and oral wart diagnosis. Results: Among 388 participants, 18% had at least one HPV genotype present before initiating ART, and 24% had at least one genotype present after 12–24 weeks of ART. Among those with undetectable oral HPV DNA before ART, median change in CD4+ count from study entry to 4 weeks after ART initiation was larger for those with detectable HPV DNA during follow-up than those without (P =  0.003). Both prevalence and incidence of oral warts were low (3% of participants having oral warts at study entry; 2.5% acquiring oral warts during 48 weeks of follow-up). Conclusion: These results suggest: effective immune control of HPV in the oral cavity of HIV-infected patients is not reconstituted by 24 weeks of ART; whereas ART initiation was not followed by an increase in oral warts, we observed an increase in oral HPV DNA detection after 12–24 weeks. The prevalence of HPV-associated oral malignancies may continue to increase in the modern ART era.

The clinical implications of HIV infection and aging.

The objectives of this study, presented as part of a plenary session at WW7 in Hyderabad, India were to review (i) the epidemiology and current clinical issues of HIV infection with regard to HIV and older populations and (ii) models for increased morbidity and mortality in older HIV-positive individuals with implications for clinical care. HIV infection for those in treatment has become a complex chronic disease in which end-organ injury and resulting morbidity, functional decline, and mortality do not have a single etiology but reflect cumulative loss of organ system reserve from multiple interacting sources leading to functional decline, organ system failure, and death. Emerging guidelines and recommendations suggest a need for increased awareness and treatment of the multifaceted needs of the aging HIV-infected patient.

A Comparison of Tenofovir-Associated Renal Function Changes in HIV-infected African Americans vs Caucasians

BACKGROUND The effects of tenofovir on renal function have been measured in multiple studies. Although African Americans are at a higher risk of developing chronic kidney disease, there are limited data examining the influence of race on tenofovir-related nephrotoxicity. METHODS This was a retrospective study of human immunodeficiency virus (HIV)-infected patients at a university-affiliated HIV clinic who were prescribed tenofovir between July 1, 2001, and January 31, 2009. The primary outcome was mean change in creatinine clearance. Secondary endpoints assessed the odds of tenofovir discontinuation secondary to nephrotoxicity, and prevalence of grade 2 to 4 serum creatinine elevation and hypophosphatemia during treatment. MAIN FINDINGS A total of 65 African American and 186 Caucasian patients were included. There were no statistically significant differences in mean change in creatinine clearance, as estimated by the Cockcroft-Gault (-14.2 mL/min vs -15.9 mL/min [P = .525]) and modification of diet in renal disease formulas (-17.2 mL/min/1.73 m2 vs -15.6 mL/min/1.73 m2 [P = .585]) between African Americans and Caucasians. Rates of tenofovir discontinuation secondary to nephrotoxicity were 6.2% and 1.6%, respectively (P = .076). Elevated baseline serum creatinine and female gender may be potential predictors for tenofovir discontinuation. CONCLUSION There were no statistically significant differences in tenofovir-related renal function changes by race as observed in our HIV patient population.

1607Veterans Aging Cohort Study (VACS) Index, Functional Status, and Other Patient Reported Outcomes in Older HIV-positive (HIV+) Adults

Other Patient Reported Outcomes in Older HIV-positive (HIV+) Adults Malcolm John, MD, MPH; Nancy Hessol, MSPH; C. Bradley Hare, MD; Catherine Lyons, NP, MPH; Roland Zepf, MS, RN; Terrence Marcotte, NP; Amanda Hutton Parrott, DPT, MS, NP; Robert Whirry, BA; Cameron Foreman, BA; Monica Gandhi, MD, MPH; Meredith Greene, MD; University of California San Francisco, San Francisco, CA; Kaiser Permanente Medical Group, San Francisco Medical Center, San Francisco, CA; Robert Whirry and Associates, Los Angeles, CA