Richard M. Rutstein

Hospital and outpatient health services utilization among HIV-infected adults in care 2000-2002.

Background:Rapid changes in HIV epidemiology and antiretroviral therapy may have resulted in recent changes in patterns of healthcare utilization. Objective:The objective of this study was to examine sociodemographic and clinical correlates of inpatient and outpatient HIV-related health service utilization in a multistate sample of patients with HIV. Design:Demographic, clinical, and resource utilization data were collected from medical records for 2000, 2001, and 2002. Setting:This study was conducted at 11 U.S. HIV primary and specialty care sites in different geographic regions. Patients:In each year, HIV-positive patients with at least one CD4 count and any use of inpatient, outpatient, or emergency room services. Sample sizes were 13,392 in 2000, 15,211 in 2001, and 14,403 in 2002. Main Outcome Measures:Main outcome measures were number of hospital admissions, total days in hospital, and number of outpatient clinic/office visits per year. Inpatient and outpatient costs were estimated by applying unit costs to numbers of inpatient days and outpatient visits. Results:Mean numbers of admissions per person per year decreased from 2000 (0.40) to 2002 (0.35), but this difference was not significant in multivariate analyses. Hospitalization rates were significantly higher among patients with greater immunosuppression, women, blacks, patients who acquired HIV through drug use, those 50 years of age and over, and those with Medicaid or Medicare. Mean annual outpatient visits decreased significantly between 2000 and 2002, from 6.06 to 5.66 visits per person per year. Whites, Hispanics, those 30 years of age and over, those on highly active antiretroviral therapy (HAART), and those with Medicaid or Medicare had significantly higher outpatient utilization. Inpatient costs per patient per month (PPPM) were estimated to be

Protease inhibitor therapy in children with perinatally acquired HIV infection.

514 in 2000,

The impact of AIDS diagnoses on long-term neurocognitive and psychiatric outcomes of surviving adolescents with perinatally acquired HIV.

472 in 2001, and

Impact of HIV severity on cognitive and adaptive functioning during childhood and adolescence.

424 in 2002; outpatient costs PPPM were estimated at

Responses to measles immunization in children infected with human immunodeficiency virus

108 in 2000,

Dendritic and Natural Killer Cell Subsets Associated with Stable or Declining CD4+ Cell Counts in Treated HIV-1–Infected Children

100 in 2001, and

School-Age Children with Perinatally Acquired HIV Infection: Medical and Psychosocial Issues in a Philadelphia Cohort

101 in 2002. Conclusion:Changes in utilization over this 3-year period, although statistically significant in some cases, were not substantial. Hospitalization rates remain relatively high among minority or disadvantaged groups, suggesting persistent disparities in care. Combined inpatient and outpatient costs for patients on HAART were not significantly lower than for patients not on HAART.

Elite Controllers are Hospitalized More Often than Persons with Medically Controlled HIV

Objective:To review the short-term response and safety of protease inhibitor therapy in HIV-infected children. Design:Retrospective chart review of open-label protease inhibitor-containing combination therapy. Setting:Two urban pediatric HIV centers. Patients:Twenty-eight HIV-infected children were prescribed 30 protease inhibitor-containing antiretroviral therapy combinations. The median age at initiation of protease inhibitor antiretroviral therapy was 79 months. Patients had been on previous antiretroviral therapy for a mean of 45.5 months. Results:Of the 28 children who completed at least 1 month of therapy, 26 experienced marked virologic and immunologic improvement (mean maximal decrease in viral load 1.90 log10 copies/ml; SD, 0.8; mean maximal rise in CD4+ lymphocytes of 279 × 106/l; SD, 300 × 106/l). Eleven patients achieved a viral nadir of < 400 copies/ml, and seven sustained this level of viral suppression for a mean of 6 months. Indinavir use was associated with a high incidence of renal side-effects, including two patients who developed interstitial nephritis. Two patients on ritonavir experienced a significant elevation of liver enzymes. Conclusions:Protease inhibitor therapy was associated with substantial short-term virologic and immunologic improvement in this primarily heavily pretreated cohort, with 25% maintaining a viral load of < 400 copies/ml after 6 months of therapy. There was a significant rate of adverse events. Pharmacokinetic and safety data are needed to guide aggressive antiretroviral therapy in HIV-infected children, and further treatment options are required for those failing or intolerant to the available protease inhibitors.

Primary Varicella and Herpes Zoster Among HIV-Infected Children From 1989 to 2006

Objective:To explore the association between previous severe HIV disease, defined as past Centers for Disease Control and Prevention class C diagnosis, and neurocognitive and psychiatric outcomes in long-term survivors of perinatally acquired HIV. Design:A retrospective cohort study of perinatally HIV-infected adolescents receiving outpatient care at a single site. Methods:Comparisons were made between those with and without class C diagnoses. Results:Eighty-one patients formed the study group, 47% were females and 72% were African–American. Median patient age was 15 years (interquartile range 13–17). Of the study group, 47% had a past class C diagnosis. The median age at class C diagnosis was 3.1 years (interquartile range 0.9–8.1). There were no significant differences between the groups with respect to most recent CD4+ cell percentage or plasma viral RNA level. Class C patients were more likely to have a history of psychiatric diagnosis [odds ratio 2.6; 95% confidence interval (CI) 1.1–6.3], psychiatric hospitalization (odds ratio 4.8; 95% CI 1.2–17.4), or learning disability (odds ratio 4.5; 95% CI 1.7–11.4). There was a significant difference in full-scale intelligence quotient between the groups (adjusted linear regression coefficient −11.7; 95% CI −17.9 to 5.5). After adjusting for age at antiretroviral therapy initiation, the associations between class C diagnosis and lower full-scale intelligence quotient, learning disorders, and psychiatric diagnoses remained significant. Conclusion:A distant history of AIDS diagnosis was associated with an increased risk of neurocognitive and psychiatric impairment in adolescents with perinatally acquired HIV. Further research should help delineate if early treatment, possibly soon after birth and definitely prior to AIDS diagnosis, might lead to improved outcomes.

Response to hepatitis B immunization by infants exposed to HIV.

Background: The influence of disease severity on cognitive and adaptive functioning in perinatally HIV-infected youth with (PHIV+/C) and without (PHIV+/NoC) a previous AIDS-defining illness (Centers for Disease Control and Prevention Class C event), compared with perinatally HIV-exposed but uninfected youth (PHEU) is not well understood. Methods: This was a cross-sectional analysis of cognitive and adaptive functioning in PHIV+/C (n = 88), PHIV+/NoC (n = 270) and PHEU (n = 200) youth aged 7–16 years, from a multisite prospective cohort study. Youth and caregivers completed the Wechsler Intelligence Scale for Children, Fourth Edition and the Adaptive Behavior Assessment System, Second Edition, respectively. We compared means and rates of impairment between groups, and examined associations with other psychosocial factors. Results: Overall mean scores on measures of cognitive and adaptive functioning were in the low average range for all 3 groups. After adjustment for covariates, mean full-scale intelligence quotient scores were significantly lower for the PHIV+/C group than the PHIV+/NoC and PHEU groups (mean = 77.8 versus 83.4 and 83.3, respectively), whereas no significant differences were observed between the PHEU and PHIV+/NoC groups in any domain. Lower cognitive performance for the PHIV+/C group was primarily attributable to a prior diagnosis of encephalopathy. No significant differences between groups were observed in adaptive functioning. Conclusion: For long-term survivors, youth with HIV infection and a prior Centers for Disease Control and Prevention Class C event have higher risk for cognitive but not adaptive impairment regardless of current health status; this finding appears attributable to a previous diagnosis of encephalopathy. Early preventive therapy may be critical in reducing risk of later neurodevelopmental impairments.