Sanghyuk S. Shin

Trends in prescriptions for highly active antiretroviral therapy in four New York City HIV clinics.

Objective: To describe trends in prescriptions for antiretroviral therapies and factors associated with prescriptions for highly active antiretroviral therapy (HAART). Methods: Medical records of patients at four HIV clinics in New York City were reviewed every 6 months. For the four 6‐month periods 1997 to 1998, we identified patients with a CD4+ nadir <500 cells/&mgr;l; sample sizes were 434, 432, 503, and 643, respectively. Trends in HAART prescriptions were tested by logistic regression using robust variance estimates because some patients contributed more than one time period. Associations between HAART prescriptions and patient characteristics were tested by χ2 and multiple logistic regression analysis. Results: Patients were predominantly black or Hispanic (89%‐90%) and male (66%‐68%), and injection drug use was the most prevalent HIV risk (38%‐49%). From 1997 to 1998, HAART prescriptions increased from 54% to 89% of antiretroviral prescriptions, and the proportion that included an nonnucleoside reverse transcriptase inhibitors (NNRTI) increased from 3% to 10%. HAART prescriptions were inversely associated with CD4+ nadir group during all time periods, and in the second half of 1998, patients with CD4+ nadir between 50 and 199 cells/&mgr;l were as likely to be prescribed HAART as the most immunosuppressed patients (CD4+ nadir <50 cells/&mgr;l; 91% versus 92%). HAART prescriptions were associated with clinic, HIV risk, and other patient characteristics in some time periods but not consistently. Conclusions: In these four HIV clinics, prescriptions for HAART increased significantly from 1997 to 1998, leveling off at 89% in the second half of 1998. Increasingly, HAART was prescribed for healthier patients and included an NNRTI.

Trends in immunologic and clinical status of newly diagnosed HIV-positive patients initiating care in the HAART era.

Objective: To evaluate whether the availability of highly active antiretroviral therapy (HAART) has motivated people at risk for HIV infection to be tested earlier. Methods: Data are from the Adult and Adolescent Spectrum of HIV Disease (ASD) Study, a chart review study of HIV‐infected people receiving care. The sample comprised newly diagnosed HIV‐positive persons initiating care at five ASD clinics in New York City (NYC) 1994 to 1999. CD4+ lymphocyte count and clinical status (asymptomatic, major AIDS‐related symptoms, AIDS‐defining opportunistic illnesses) at first visit were ascertained. Trends in these two outcomes were analyzed comparing each time period after the second half of 1996 with the aggregate period from 1994 to the first half of 1996. Results: Between 1994 and 1999, we identified 545 patients newly diagnosed as positive for HIV with a first visit to an ASD clinic. Patients were predominantly black or Hispanic (93%). The mean CD4+ count at baseline was 246 cells/Symboll and the median was 152 cells/Symboll. After adjusting for covariates, the mean CD4+ count of newly diagnosed HIV‐positive patients was significantly lower (p = .04) only during the second half of 1997. The proportion of patients who were asymptomatic at baseline ranged from 29% in the second half of 1998 to 61% in the first half of 1994 (&KHgr;2 = 48.8; p = .0008). After adjustment for covariates, the probability of a patient having a major symptom or an opportunistic illness at baseline was significantly higher only during the second half of 1998 (p = .001). Symbol. No caption available. Discussion During most time periods, both before and after the introduction of HAART, most newly diagnosed patients at these five HIV clinics in NYC were immune suppressed and symptomatic.

High Treatment Success Rates Among HIV-Infected Multidrug-Resistant Tuberculosis Patients After Expansion of Antiretroviral Therapy in Botswana, 2006-2013.

Background: Few studies have examined multidrug-resistant (MDR) tuberculosis (TB) treatment outcomes among HIV-infected persons after widespread expansion of antiretroviral therapy (ART). We describe MDR-TB treatment outcomes among HIV-infected and HIV-uninfected patients in Botswana after ART expansion. Methods: We retrospectively reviewed data from patients who started MDR-TB therapy in Botswana during 2006–2013. Multivariable regression models were used to compare treatment outcomes between HIV-infected and HIV-uninfected patients. Results: We included 588 MDR-TB patients in the analysis, of whom, 47 (8.0%) and 9 (1.5%) were diagnosed with pre-extensively drug-resistant (XDR)-TB and XDR-TB, respectively. Of the 408 (69.4%) HIV-infected patients, 352 (86.0%) were on ART or started ART during treatment, and median baseline CD4+ T-cell count was 234 cells/mm3. Treatment success rates were 79.4% and 73.0% among HIV-uninfected and HIV-infected patients, respectively (P = 0.121). HIV-infected patients with CD4+ T-cell count <100 cells/mm3 were more likely to die during treatment compared with HIV-uninfected patients (adjusted risk ratio = 1.890; 95% CI: 1.098 to 3.254). Conclusions: High rates of treatment success were achieved with programmatic management of MDR-TB and HIV in Botswana after widespread expansion of ART. However, a 2-fold increase in mortality was observed among HIV-infected persons with baseline CD4+ <100 cells/mm3 compared with HIV-uninfected persons.

Collision of Three Pandemics: The Coexistence of Cervical Cancer, HIV Infection, and Prior Tuberculosis in the Sub-Saharan Country of Botswana

Cervical cancer is the leading cause of cancer-related mortality in the developing world, where HIV and Mycobacterium tuberculosis (TB) infection are also endemic. HIV infection is independently associated with increased morbidity and mortality among women with cervical cancer. TB is believed to increase the risk of malignancies and could cause chronic inflammation in the gynecologic tract. However, the relationship between cervical cancer and TB in settings hyperendemic for HIV is unknown. We found that 18 (10%) of a cohort of 180 women with cervical cancer in Botswana had a history of TB disease. Age and HIV infection were also associated with a history of TB disease. Our data show that prior TB disease is highly prevalent among patients with cervical cancer infected with HIV. The coexistence of cervical cancer, HIV infection, and prior TB infection might be higher than expected in the general population. Prospective studies are needed to better determine the impact of the collision of these three world health epidemics.

Missed Opportunity to Prevent Tuberculosis

A letter to the editor is presented in response to the article Preventing infectious pulmonary tuberculosis among foreign-born residents of the United States by A.L. Davidow, D. Katz, S. Ghosh and others and published in a 2015 issue of the journal.

Mixed Mycobacterium tuberculosis–Strain Infections Are Associated With Poor Treatment Outcomes Among Patients With Newly Diagnosed Tuberculosis, Independent of Pretreatment Heteroresistance

BackgroundnHeteroresistant Mycobacterium tuberculosis infections (defined as concomitant infection with drug-resistant and drug-susceptible strains) may explain the higher risk of poor tuberculosis treatment outcomes observed among patients with mixed-strain M. tuberculosis infections. We investigated the clinical effect of mixed-strain infections while controlling for pretreatment heteroresistance in a population-based sample of patients with tuberculosis starting first-line tuberculosis therapy in Botswana.nnnMethodsnWe performed 24-locus mycobacterial interspersed repetitive unit-variable number tandem-repeat analysis and targeted deep sequencing on baseline primary cultured isolates to detect mixed infections and heteroresistance, respectively. Drug-sensitive, micro-heteroresistant, macro-heteroresistant, and fixed-resistant infections were defined as infections in which the frequency of resistance was <0.1%, 0.1%-4%, 5%-94%, and ≥95%, respectively, in resistance-conferring domains of the inhA promoter, the katG gene, and the rpoB gene.nnnResultsnOf the 260 patients with tuberculosis included in the study, 25 (9.6%) had mixed infections and 30 (11.5%) had poor treatment outcomes. Micro-heteroresistance, macro-heteroresistance, and fixed resistance were found among 11 (4.2%), 2 (0.8%), and 11 (4.2%), respectively, for isoniazid and 21 (8.1%), 0 (0%), and 10 (3.8%), respectively, for rifampicin. In multivariable analysis, mixed infections but not heteroresistant infections independently predicted poor treatment outcomes.nnnConclusionsnAmong patients starting first-line tuberculosis therapy in Botswana, mixed infections were associated with poor tuberculosis treatment outcomes, independent of heteroresistance.

Correlates of Treatment Readiness Among Formerly Incarcerated Homeless Women

Treatment readiness is a key predictor of drug treatment completion, rearrest, and recidivism during community reentry; however, limited data exist among homeless female offenders (HFOs). The purpose of this study was to present baseline data from a randomized controlled trial of 130 HFOs who had been released from jail or prison. Over half (60.8%) of HFOs had a treatment readiness score of ≥40 (n = 79, mean [μ] = 40.2, SD = 8.72). Bivariate analyses revealed that methamphetamine use, psychological well-being, and high emotional support were positively associated with treatment readiness. On the contrary, depressive symptomatology and depression/anxiety scores were negatively associated with the treatment readiness score. Multiple linear regression revealed that depressive symptomatology was negatively associated with treatment readiness (β = −0.377, p = .001). Further analyses revealed that the effect of emotional support on treatment readiness was mediated by depressive symptomatology.

Household Food Insecurity as Mediator of the Association Between Internalized Stigma and Opportunistic Infections

Internalized HIV stigma can affect health outcomes, but the mechanism underlying this relationship is poorly understood. We investigated the potential pathways for the association between internalized stigma and opportunistic infections (OIs) among women living with HIV in rural India. We conducted a cross-sectional study involving in-person interviews with 600 participants. We modeled two outcome variables, total number of OIs and fungal dermatoses, which was the most frequently reported OI. Causal mediation analysis was performed to estimate the total effect, direct effect, and indirect effect through mediators while controlling for confounders. Food insecurity was a strong mediator of the association between internalized stigma and the number of OIs (70% of the total effect) and fungal dermatoses (83% of the total effect), while the indirect effect of stigma through adherence was minimal for both outcomes. Household food insecurity may be an important mediator of the impact of HIV-related stigma on opportunistic infections.

Achieving Drug and Alcohol Abstinence Among Recently Incarcerated Homeless Women: A Randomized Controlled Trial Comparing Dialectical Behavioral Therapy-Case Management With a Health Promotion Program

Background Homeless female ex-offenders (homeless female offenders) exiting jail and prison are at a critical juncture during reentry and transitioning into the community setting. Objective The purpose of the study was to compare the effect of a dialectical behavioral therapy-case management (DBT-CM) program with a health promotion (HP) program on achieving drug and alcohol abstinence among female parolees/probationers residing in the community. Methods We conducted a multicenter parallel randomized controlled trial with 130 female parolees/probationers (aged 19–64 years) residing in the community randomly assigned to either DBT-CM (n = 65) or HP (n = 65). The trial was conducted in four community-based partner sites in Los Angeles and Pomona, California, from February 2015 to November 2016. Treatment assignment was carried out using a computer-based urn randomization program. The primary outcome was drug and alcohol use abstinence at 6-month follow up. Results Analysis was based on data from 116 participants with complete outcome data. Multivariable logistic regression revealed that the DBT-CM program remained an independent positive predictor of decrease in drug use among the DBT-CM participants at 6 months (p = .01) as compared with the HP program participants. Being non-White (p < .05) and having higher depressive symptom scores (p < .05) were associated with lower odds of drug use abstinence (i.e., increased the odds of drug use) at 6 months. Discussion DBT-CM increased drug and alcohol abstinence at 6-month follow-up, compared to an HP program.

Geospatial modelling in guiding health program strategies in resource-limited settings-the way forward.

Public health decision-making is a complex process that demands careful rational and ethical reasoning based on sound scientific evidence. When evaluating the potential benefits and outcomes of public health programs, policymakers often find themselves in challenging situations due to competing needs, limited resources, and lack of access to quality data, among others. In recent years, mathematical modelling has gained increasing popularity in public health practice for its ability to assist with projecting outcomes of intervention strategies and policies.