Sharon Weissman

The Impact of Cigarette Smoking on Mortality, Quality of Life, and Comorbid Illness Among HIV‐Positive Veterans

AbstractBACKGROUND: The impact of smoking on outcomes among those with HIV infection has not been determined in the era of highly active antiretroviral therapy (HAART). STUDY OBJECTIVE: Determine the impact of smoking on morbidity and mortality in HIV-positive patients post-HAART. DESIGN: Prospective observational study. PARTICIPANTS: Eight hundred and sixty-seven HIV-positive veterans enrolled in the Veterans Aging Cohort 3 Site Study. MEASUREMENTS: Clinical data were collected through patient questionnaire, International Classification of Diseases—9th edition codes, and standardized chart extraction, and laboratory and mortality data through the national VA database. Quality of life was assessed with the physical component summary (PCS) of the Short-Form 12. RESULTS: Current smokers had increased respiratory symptoms, chronic obstructive pulmonary disease (COPD), and bacterial pneumonia. In analyses adjusted for age, race/ethnicity, CD4 cell count, HIV RNA level, hemoglobin, illegal drug and alcohol use, quality of life was substantially decreased (β=−3.3, 95% confidence interval [CI] −5.3 to −1.4) and mortality was significantly increased (hazard ratio 1.99, 95% CI 1.03 to 3.86) in current smokers compared with never smokers. CONCLUSIONS: HIV-positive patients who currently smoke have increased mortality and decreased quality of life, as well as increased respiratory symptoms, COPD, and bacterial pneumonia. These findings suggest that smoking cessation should be emphasized for HIV-infected patients.

Medical disease and alcohol use among veterans with human immunodeficiency infection: A comparison of disease measurement strategies.

Background:Many people with human immunodeficiency (HIV) infection drink alcohol. We asked whether level of exposure to alcohol is associated with medical disease in a linear or nonlinear manner, whether the association depends upon the proximity of alcohol use, and whether it varies by source used to measure disease (chart review vs. ICD-9 Diagnostic Codes). Methods:The Veterans Aging 3 Site Cohort Study (VACS 3) enrolled 881 veterans, 86% of all HIV-positive patients seen, at 3 VA sites from June 23, 1999, to July 28, 2000. To maximize the sensitivity for alcohol exposure, alcohol use was measured combining data from patient self-report, chart review, and ICD-9 codes. We assigned the greatest exposure level reported from any source. Alcohol use within the past 12 months was considered current. Data on comorbid and AIDS-defining medical diseases were collected via chart review and ICD-9 diagnostic codes. The association of alcohol use (level and timing) and disease was modeled only for diseases demonstrating ≥10% prevalence. Linearity was compared with nonlinearity of association using nested multivariate models and the likelihood ratio test. All multivariate models were adjusted for age, CD4 cell count, viral load, intravenous drug use, exercise, and smoking. Results:Of 881 subjects enrolled, 866 (98%) had sufficient data for multivariate analyses, and 876 (99%) had sufficient data for comparison of chart review with ICD-9 Diagnostic Codes. Of the 866, 42 (5%) were lifetime abstainers; 247 (29%) were past drinkers; and 577 (67%) were current users. Among the 824 reporting past or current alcohol use, 341 (41%) drank in moderation, 192 (23%) drank hazardously, and 291 (35%) carried a diagnosis of abuse or dependence. ICD-9 codes showed limited sensitivity, but overall agreement with chart review was good for 15 of 20 diseases (kappa >0.4). The following diseases demonstrated a ≥10% prevalence with both measures (hepatitis C, hypertension, diabetes, obstructive lung disease, candidiasis, and bacterial pneumonia). All of these were associated with alcohol use (P < 0.05). Hepatitis C, hypertension, obstructive lung disease, candidiasis, and bacterial pneumonia demonstrated linear associations with level of alcohol use (P < 0.03). Past alcohol use increased the risk of hepatitis C and diabetes after adjustment for level of exposure (P < 0.01). With the exception of candidiasis, the associations between level and timing of alcohol use were similar when measured by ICD-9 codes or by chart review. Conclusions:Past and current use of alcohol is common among those with HIV infection. Estimates of disease risk associated with alcohol use based upon ICD-9 Diagnostic Codes appear similar to those based upon chart review. After adjustment for level of alcohol exposure, past use is associated with similar (or higher) prevalence of disease as among current drinkers. Finally, level of alcohol use is linearly associated with medical disease. We find no evidence of a “safe” level of consumption among those with HIV infection.

Clinical Importance of HIV and Depressive Symptoms Among Veterans with HIV Infection

OBJECTIVE: To compare the clinical importance (association with illness severity and survival) of depressive and HIV symptoms among veterans with HIV infection.DESIGN: Cross-sectional study; survival analysis.SETTING: Infectious Disease Clinics at 3 VA Medical Centers.PARTICIPANTS: HIV-infected patients (N=881) and their health care providers from June 1999 through July 2000.MEASUREMENTS AND MAIN RESULTS: Depressive symptoms were assessed using the 10-item Centers for Epidemiologic Studies Depression Scale (CES-D). Patient baseline survey included an HIV Symptom Index measuring the frequency and bother of 20 common symptoms. Providers were surveyed on patients’ illness severity, and survival data were obtained from VA death records. Of 881 patients, 46% had significant depressive symptoms (CES-D ≥10). Increasing depression symptom severity was associated with increasing HIV symptom frequency (P<.001) and bother (P<.001). Multiple regression results revealed that having moderate or severe depressive symptoms was not associated with provider-reported illness severity or survival. However, HIV symptoms were significantly associated with provider-reported illness severity (P<.01) and survival (P=.05), after adjusting for moderate and severe depressive symptoms, CD4 cell count/mm3, viral load, age, race, and antiretroviral use.CONCLUSIONS: Depression, while common in this sample, was not associated with illness severity or mortality after adjusting for HIV symptoms. HIV symptoms are associated with severity of illness and survival regardless of patients’ severity of depressive symptoms. This suggests that equal medical consideration should be given to HIV symptoms presented by HIV-infected patients regardless of their depression status, rather than automatically attributing medical complaints to depression.

Prevalence of chronic kidney disease in an urban HIV infected population.

Background:The prevalence of chronic kidney disease in an HIV-infected population during the highly active antiretroviral era has not been fully evaluated. Methods:A retrospective chart review of HIV-infected patients seen in 2004 was conducted to determine the prevalence of chronic kidney disease (CKD), using the 2004 National Kidney Foundations CKD staging criteria. Glomerular filtration rate (GFR) was calculated, using the Modification of Diet in Renal Disease formula. Univariate analyses were performed comparing individuals with normal kidney function and those with CKD. Multivariate analysis was conducted including all variables with a value of P < 0.1. Results:We found evidence of CKD in 24% of the patients. Forty patients (10%) had stage 1 CKD, 19 patients (4%) stage 2, 29 patients (7%) stage 3, 4 patients (1%) stage 4, and 8 patients (2%) stage 5. Patients with CKD are more likely to be African American (AA), older, have AIDS, lower CD4 counts and higher HIV viral loads. Patients with CKD were also more likely to have hypertension (HTN), diabetes mellitus (DM), or both. Indinavir or tenofovir exposure was associated with CKD. In multivariate analysis HTN, AA race, or HTN and DM were the only significant predictors of CKD. Physicians did not identify CKD in 74% of patients. Renal biopsies were done in 10 patients; 5 had HIV-associated nephropathy. Conclusions:Substantial minorities of HIV-infected patients have CKD. AA race or the presence of HTN or HTN and DM is associated with CKD. Clinicians often do not note the presence of CKD in this population.

Testing, Referral, and Treatment Patterns for Hepatitis C Virus Coinfection in a Cohort of Veterans with Human Immunodeficiency Virus Infection

We examined testing, referral, and treatment of patients with hepatitis C among HIV-infected patients in the Veterans Aging 3-Site Cohort Study by using patient- and provider-completed surveys and laboratory, pharmacy, and administrative records from the Department of Veterans Affairs electronic medical record. Of 881 human immunodeficiency virus-positive patients, 43% were coinfected with hepatitis C virus. Of these, 88 (30%) reported current alcohol consumption. Only one-third were counseled to reduce or stop alcohol consumption. Coinfected patients with indications for hepatitis C treatment had a high rate of contraindications, including both medical and psychiatric comorbidities. Of the 65 patients with indications for hepatitis C therapy and free of contraindications for treatment, only 18% underwent liver biopsy and 3% received IFN. Although treatment indications are common in this population, contraindications are also common. Health care providers are often unaware of alcohol consumption that may accelerate the course of hepatitis C, increase the risk of hepatocellular carcinoma, and reduce treatment efficacy.

Differences in symptom expression in older HIV-positive patients: The Veterans Aging Cohort 3 Site Study and HIV Cost and Service Utilization Study experience

Summary: Symptom recognition is critical for patient care but has been little studied in older HIV‐infected individuals. The authors examined differences in symptom expression between younger (younger than age 50 years) and older (older than age 50 years) HIV‐infected individuals. The authors analyzed data from two cross‐sectional studies of HIV‐infected individuals: 2864 individuals from the HIV Cost and Service Utilization Study (HCSUS) and 881 individuals from the Veterans Aging Cohort 3 Site Study (VACS 3). The authors compared the prevalence of eight symptoms common to both studies and 10 symptoms examined only in the VACS 3 population, stratified by age and race. Disease severity was assessed by CD4 count and 18 HIV‐related diseases reported. Multivariate logistic regression models were used to account for demographics and severity differences. VACS 3 versus HCSUS participants were more likely nonwhite and older. In unadjusted comparisons, older nonwhites were less likely to report experiencing symptoms than younger whites. They reported the fewest total number of symptoms and the fewest individual symptoms common to both studies (headache, fever, nausea/vomiting, and diarrhea) or in the VACS 3 only (dizziness, sleeping difficulty, fatigue, rashes, bloating, and myalgias/arthalgias). Multivariate regression estimates suggest older age predicts a greater likelihood of reporting peripheral neuropathy, weight loss, or hair loss, but a lower likelihood of reporting headaches, depressed mood, white oral patches, or diarrhea. Nonwhites appeared less likely to report symptoms. Age is a determinant of reporting certain symptoms in HIV disease but may be masked or accentuated by other factors such as race.

Association of hypocholesterolaemia with hepatitis C virus infection in HIV-infected people*

To study the impact of hepatitis C virus (HCV) status on serum cholesterol levels in HIV‐infected patients.

Routine Anal Cytology Screening for Anal Squamous Intraepithelial Lesions in an Urban HIV Clinic

Objectives: The purpose of this study is to describe our experience with routine anal cancer screening using anal cytology, determine risk factors for abnormal anal cytology, and determine if an association exists between cytology and histology in patients with HIV infection. Methods: Demographics, CD4+ T-cell count, STD history, and cytology and histology data were extracted from medical charts of patients seen between November 1, 2002, and November 30, 2004. Analysis was done using &khgr;2 for comparison of proportions and Student t test for continuous variables. Multivariate analysis was conducted using logistic regression controlling for age, race, sex, CD4+ T-cell nadir, and HIV exposure category. Results: Overall, 276 of 560 of the clinic patients received a screening anal cytology during the study period. Of these patients, 11 were excluded from the analysis and 74 of 265 (27.9%) patients screened had an abnormal anal cytology. Mean age was 44 years, and 68% were men. Forty-nine percent were African American, 34% Caucasian, and 17% Hispanic. Those with an abnormal cytology were more likely to be Caucasian (P = 0.03), and be homosexual or bisexual (P = 0.02). They were also more likely to have a lower CD4+ nadir (142 cells/mm3 vs. 223 cells/mm3, P = 0.005) and CD4+ at time of anal cytology (353 cells/mm3 vs. 497 cells/mm3, P <0.001). Those with an abnormal anal cytology also had higher occurrence of anal disease on perianal visual inspection (30% vs. 9%, P <0.001) and were more likely to have a history of genital warts (23% vs. 12%, P = 0.02) or herpes (35% vs. 22%, P = 0.02). Two patients had anal intraepithelial neoplasia (AIN) I, 2 AIN II, 3 AIN III, and 2 squamous cell carcinoma in situ on histology. There was no apparent association between cytology and histology. Conclusion: Routine anal cytology screening is a feasible tool to incorporate into HIV care for patients regardless of gender and HIV risk factors. Its impact on morbidity and mortality warrant further study.

The Survival Experience of Older and Younger Adults with AIDS: Is there a Growing Gap in Survival?

Older people with HIV infection die faster than younger counterparts, but it is notknown whether age-associated survival is changing over time. The authors used theCenters for Disease Control data set of adult cases of AIDS reported from January 1,1981, to December 31, 1994, to study age-associated differences in survival by yearof diagnosis. A total of 433,354 adults with AIDS were reported during this interval.Of these, 10.3% were younger than age 50. In 1983-1984, median survival for olderand younger people was 153 versus 274 days, respectively. By 1991-1992, mediansurvival had improved for both groups-396 and 731 days, respectively. However,the relative and absolute gap in survival grew. While a substantially larger proportionof older adults died within 90 days of diagnosis, the overall trend of an increasingage-associated gap in survival remained when these were excluded from the analysis.Older and younger people with AIDS have achieved prolonged survival, but theage-associated gap in survival has grown.

The Continuum of HIV Care in Rural Communities in the United States and Canada: What Is Known and Future Research Directions

Abstract: The nature of the HIV epidemic in the United States and Canada has changed with a shift toward rural areas. Socioeconomic factors, geography, cultural context, and evolving epidemics of injection drug use are coalescing to move the epidemic into locations where populations are dispersed and health care resources are limited. Rural–urban differences along the care continuum demonstrate the implications of this sociogeographic shift. Greater attention is needed to build a more comprehensive understanding of the rural HIV epidemic in the United States and Canada, including research efforts, innovative approaches to care delivery, and greater community engagement in prevention and care.