Robin A. Jeffries

Behaviors of recently HIV-infected men who have sex with men in the year postdiagnosis: effects of drug use and partner types.

Objectives:Assess behavior change of recently HIV-infected men who have sex with men (MSM). Methods:From 2002 to 2006, 193 recently HIV-infected MSM in the Southern California Acute Infection and Early Disease Research Program were interviewed every 3 months. Changes in HIV status of partners, recent unprotected anal intercourse (UAI), drug use, use of antiretroviral therapy (ART), detectable viral load, and partnership dynamics over 1 year were used to predict recent UAI in a random effect logistic regression. Results:Over a year significantly fewer partners in the past 3 months were reported (mean 8.81 to 5.84; P < 0.0001). Percentage of recent UAI with HIV-status unknown last partners decreased from enrollment to 9 months (49%-27%) and rebounded at 12 months to 71%. In multivariable models controlling for ART use, recent UAI was significantly associated with: baseline methamphetamine use [adjusted odds ratio (AOR): 7.65, 95% confidence interval (CI): 1.87 to 31.30], methamphetamine use at follow-up (AOR: 14.4, 95% CI: 2.02 to 103.0), HIV-uninfected partner at follow-up (AOR: 0.14, 95% CI: 0.06 to 0.33), and partners with unknown HIV status at follow-up (AOR: 0.33, 95% CI: 0.11 to 0.94). HIV viral load did not influence rate of UAI. Conclusions:Transmission behaviors of these recently HIV-infected MSM decreased and serosorting increased after diagnosis; recent UAI with serostatus unknown or negative partners rebounded after 9 months, identifying critical timepoints for interventions targeting recently HIV-infected individuals. There was no evidence in this cohort that the viral load of these recently infected men guided their decisions about protected or unprotected anal intercourse.

The slippery slope: lubricant use and rectal sexually transmitted infections: a newly identified risk.

Background: Use of lubricant products is extremely common during receptive anal intercourse (RAI) yet has not been assessed as a risk for acquisition of sexually transmitted infections (STIs). Methods: Between 2006 and 2008, a rectal health and behavior study was conducted in Baltimore and Los Angeles as part of the University of California, Los Angeles Microbicide Development Program (NIAID IPCP# #0606414). Participants completed questionnaires, and rectal swabs were tested for Neisseria gonorrhoeae and Chlamydia trachomatis with the Aptima Combo 2 assay, and blood was tested for syphilis (for RPR and TPHA with titer) and HIV. Of those reporting lubricant use and RAI, STI results were available for 380 participants. Univariate and multivariate regressions assessed associations of lubricant use in the past month during RAI with prevalent STIs. Results: Consistent lubricant use during RAI in the past month was reported by 36% (137/380) of participants. Consistent past month lubricant users had a higher prevalence of STI than inconsistent users (9.5% vs. 2.9%; P = 0.006). In a multivariable logistic regression model, testing positive for STI was associated with consistent use of lubricant during RAI in the past month (adjusted odds ratio: 2.98 95% confidence interval: 1.09, 8.15) after controlling for age, gender, study location, HIV status, and numbers of RAI partners in the past month. Conclusions: Findings suggest some lubricant products may increase vulnerability to STIs. Because of wide use of lubricants and their potential as carrier vehicles for microbicides, further research is essential to clarify if lubricant use poses a public health risk.

Coronary atherosclerotic lesions in human immunodeficiency virus–infected patients: a histopathologic study

BACKGROUND Studies suggest human immunodeficiency virus-positive (HIV+) patients have an increased risk of coronary artery disease (CAD), yet little is known about the histopathology, severity, or distribution of lesions. METHODS The coronary arteries of 66 deceased AIDS patients and 19 HIV controls (age <55) were dissected and graded for percent luminal stenosis by intimal lesions, percent of intima involved with lipid, and extent of intimal calcification on a scale of 0 to 3. Medical histories, antiretroviral therapies, and CAD risk factors were reviewed. RESULTS HIV+ patients were older than controls (P=.06), and more were male (P=.02). Thirty-five percent of HIV+ patients had stenosis >or=75% of at least one artery. Compared to controls, HIV+ patients had three times greater odds of stenosis >or=75%, controlling for age and sex (one-sided P=.03). Older age and male sex were also risk factors (one-sided P<.001). HIV seropositivity was associated with increased plaque lipid content (one-sided P=.02) and calcification (one-sided P=.08). Duration of HIV infection, antiretroviral therapy, and immune status did not predict severe disease in multivariate analyses. Previously unreported patterns of dystrophic calcification were observed in HIV+ patients and older controls. CONCLUSIONS Young to middle-aged patients dying from advanced AIDS have atherosclerotic CAD that may result in luminal narrowing, heavy calcification, and high plaque lipid content. The pattern of disease, location of lesions, and plaque composition are typical of atherosclerosis in HIV-negative patients. No relationship between antiretroviral therapies and atherosclerosis was seen in this small study of heavily treated patients.

The chromophobe tumor grading system is the preferred grading scheme for chromophobe renal cell carcinoma.

PURPOSE The prognostic usefulness of the Fuhrman nuclear grading system has been questioned for chromophobe renal cell carcinoma due to its frequent nuclear and nucleolar pleomorphism. Chromophobe tumor grade, a novel 3-tier tumor grading system based on geographic nuclear crowding and anaplasia, was recently reported to be superior to the Fuhrman system. We compared the 2 scoring systems in a large sporadic chromophobe renal cell carcinoma cohort to determine which grading scheme provides the most predictive assessment of clinical risk. MATERIALS AND METHODS We identified a total of 84 cases of sporadic chromophobe renal cell carcinoma in 82 patients from a total of 2,634 cases (3.2%) spanning 1989 to 2010. A subset of 11 tumors had secondary areas of sarcomatoid transformation. All cases were reviewed for Fuhrman nuclear grade and chromophobe tumor grade according to published parameters by an expert genitourinary pathologist blinded to clinicopathological information. RESULTS The distribution of Fuhrman nuclear grades 1 to 4 was 0%, 52.4%, 32.9% and 14.7% of cases, and the distribution of chromophobe tumor grades 1 to 3 was 48.8%, 36.5% and 14.7%, respectively. Metastasis developed in 20 patients (24.4%). Survival analysis revealed statistically significant differences in recurrence-free survival when adjusted for chromophobe tumor grade and Fuhrman nuclear grade. Chromophobe tumor grade showed a slightly higher AUC for recurrence-free survival and overall survival than the Fuhrman nuclear grading system. Neither chromophobe tumor grade nor Fuhrman nuclear grade was retained as an independent predictor of outcome in multivariate modeling when patients with sarcomatoid lesions were excluded. CONCLUSIONS Chromophobe tumor grade effectively stratifies patients with chromophobe renal cell carcinoma across all grading levels. Since it does not rely on nuclear features, it avoids the hazard of overestimating the malignant potential of chromophobe renal cell carcinoma. Overall chromophobe tumor grade has higher predictive accuracy than the Fuhrman nuclear grading system.

Effect of mild renal dysfunction (s-crea 1.2–2.2 mg/dl) on presentation characteristics and short- and long-term outcomes of on-pump cardiac surgery patients

OBJECTIVES The objective of this study is to evaluate differences in patient presentation and short- and long-term outcomes between patients dichotomized by the level of preoperative s-creatinine (s-crea) without renal failure and to use EuroSCORE (ES) risk stratification for validating differences and for predictive purposes. METHODS A thousand consecutive cardiac surgery patients from January 1999 through May 2000 were analyzed. Patients with off-pump surgery or s-crea >200 micromol/l (>2.2 mg/dl) were excluded leaving 885 patients for analysis. Group 1 (n=703) had s-crea 0.5-1.2 mg/dl and Group 2 (n=182) had elevated s-crea 1.3-2.2 mg/dl but no renal insufficiency. RESULTS Group 2 patients were older (P<0.0001), had a higher percentage of males (P=0.008), had lower left ventricular ejection fraction (LVEF) (P=0.001), had higher New York Heart Association (NYHA) classification (P<0.0001), had more diabetics (P=0.001) and had more patients with a history of congestive heart failure (CHF) (P<0.0001). Both additive ES (AES) and logistic ES (LES) variables were higher in Group 2 patients, AES 8.45+/-4.28% vs. 6.05+/-3.80% (P<0.0001) and LES 17.7+/-19.1% vs. 9.57+/-13.3% (P<0.0001). Proportions of emergency operations and use of intra-aortic balloon pulsation (IABP) support did not differ. There were more coronary artery bypass grafting (CABG) with or without concomitant procedures in Group 1 but otherwise the procedures performed were similar. Cardiopulmonary bypass (CPB) times did not differ (P=0.1). Operative mortality was similar (P=0.06) but hospital mortality was higher in Group 2: 19/10.4% vs. 25/3.6% (P<0.0001), odds ratio (OR) 3.16. Total length of stay (LOS) and length of stay in the postoperative intensive care unit (ICU) did not differ. Postoperative renal failure (PORF) (s-crea increase to >2.25 mg/dl or >200 micromol/l) developed in 38/4.5% patients in Group 1 and in 41/22.5% patients in Group 2 (P<0.0001), OR=5.08. Follow-up all-cause mortality was higher in Group 2: 68/37.4% vs. 167/23.8% (P<0.0001), OR=1.91. Both ES definitions predicted hospital mortality, LOS, ICU, PORF and long-term mortality well, while increased s-crea predicted PORF and long-term mortality in both groups. CONCLUSIONS Mild increase in s-crea is a marker for patients with increased cardiac risk factors and the risk for poor outcomes. Both ES definitions are highly predictive of the outcomes.

Order of orifices: Sequence of condom use and ejaculation by orifice during anal intercourse among women: Implications for HIV transmission

Background:For women, the order of penile insertion, condom use, and ejaculation by orifice during sexual events affects the probability of HIV transmission and design of HIV prevention methods. Methods:From October 2006 to June 2009, 431 women in Los Angeles and Baltimore in a rectal health study reported the sequence of penile insertion, condom use, and ejaculation by orifice location by computer-assisted self-interview. Multinomial logistic regression identified predictors of condom use by orifice among women who reported vaginal intercourse (VI) during their last anal intercourse (AI) event. Results:Of the 192 reporting on a last AI event, 96.3% (180/187) reported VI. Of these, 83.1% had VI before AI. Including the 36% who ejaculated in both the rectum and vagina, 66% report any ejaculation in the vagina and 45% in the rectum. One-third used a condom for both VI and AI, <10% for VI only or AI only, and half used no condoms. After adjusting for race, partner type, and substance use, compared with women who used condoms for both VI and AI at last AI, being older (units = 5 years) [adjusted odds ratio (AOR) = 0.76; 95% confidence interval (CI): 0.60 to 0.96], with serodiscordant partners (AOR = 0.22; 95% CI: 0.08 to 0.61), and HIV-positive with seroconcordant partners (AOR = 0.15; 95% CI: 0.04 to 0.54) were associated with not using condoms. Conclusions:For most of the women in our study VI accompanied AI, with AI usually occurring after VI. This evidence for use of multiple orifices during the same sexual encounter and low use of condoms across orifices supports the need for a multicompartment HIV prevention strategy.

O2-S2.01 The project connect health systems intervention: STD screening and HIV testing outcomes for female adolescents

Background Access to STD screening and HIV testing are important components of sexual and reproductive health care for adolescents. However, few youth have ever had an STD or HIV test, suggesting a need for new approaches to linking adolescents to care. Project Connect is an 8 year, quasi-experimental study of a multi-level intervention to prevent STD, HIV, and teen pregnancy. The Health Systems Intervention component was designed to provide an effective conduit to link youth to available health care services. Community health care providers who offered adolescents high quality care were identified and recruited for a referral system implemented through school nurses. Methods Six intervention and six control high schools in a public school district in the Los Angeles, California area participated in the study. Analyses included survey data from 6623 sexually experienced (ever engaged in sexual intercourse) and 4703 sexually active (engaged in intercourse in the past 3 months) female high school students across 5 years (T1–T5). Both samples were 78% Latino and 13% African American; the mean age was 16.6. A mixed model logistic regression analysis was used to test for intervention effects. Random effects on the student level were included to control for repeated measures. Results Statistically significant intervention effects were observed overall among both samples (see Abstract O2-S2.01 table 1 for adjusted OR and 95% CIs for sexually experienced sample) for receiving STD testing or treatment in the past year and ever being tested for HIV. At T1, for example, 18% of sexually experienced intervention females reported being tested/treated for an STD in the past year; at T5, 29.2% reported having done so. In the control condition, 17% reported STD testing/treatment in the past year at T1, which remained relatively stable by T5, at 19.9%. Among sexually experienced females statistically significant increases were also found for ever being tested for an STD. Abstract O2-S2.01 Table 1 Adjusted OR for the change between time points in sexually experienced females Time point paired difference AOR (95% CI) STD test/Tx past year Ever STD test Ever HIV test T2-T1 1.12 (0.66 to 1.98) 1.06 (0.57 to 1.97) 1.16 (0.59 to 2.26) T3-T1 1.73 (1.02 to 2.95)* 1.44 (0.77 to 2.70) 1.42 (0.73 to 2.28) T4-T1 1.67 (0.965 to 2.87) 1.97(1.03 to 3.77)* 2.20 (1.10 to 4.39)* T5-T1 1.93 (1.14 to 3.26)* 1.28 (0.68 to 2.41) 1.94 (0.99 to 3.81) T3-T2 1.55 (0.93 to 2.56) 1.36 (0.75 to 2.45) 1.23 (0.65 to 2.32) T4-T2 1.49 (0.88 to 2.51) 1.86 (0.99 to 3.48) 1.90 (0.97 to 3.71) T5-T2 1.72 (1.04 to 2.85)* 1.21 (0.66 to 2.22) 1.67 (0.86 to 3.24) T4-T3 0.96 (0.57 to 1.62) 1.36 (0.74 to 2.50) 1.55 (0.81 to 2.96) T5-T3 1.11 (0.67 to 1.84) 0.89 (0.49 to 1.61) 1.37 (0.72 to 2.59) T5-T4 1.16 (0.70 to 1.91) 0.65 (0.36 to 1.18) 0.88 (0.47 to 1.65) * p<0.05. Conclusions Project Connect was successful in linking female adolescents to sexual and reproductive health care through high school nurses. Rather than attempting to change provider behaviour, this structural intervention capitalises on existing, adolescent-focused expertise among local medical providers. It is a low-cost, sustainable strategy for linking (or ensuring access for) adolescents to care and could be widely implemented.