Virginia L. Kan

Is Frequent CD4+ T-Lymphocyte Count Monitoring Necessary for Persons With Counts ≥300 Cells/µL and HIV-1 Suppression?

Among patients infected with human immunodeficiency virus (HIV), those with HIV-1 RNA <200 copies/mL and CD4 counts ≥300 cells/µL had a 97.1% probability of maintaining durable CD4 ≥200 cells/µL for 4 years. When non-HIV causes of CD4 lymphopenia were excluded, the probability rose to 99.2%. Our data support less frequent CD4 monitoring during viral suppression.

Trichosporon asahii infection in an advanced AIDS patient and literature review.

We were very surprised when we read the report by Martinez-Steele et al. [1] concerning an observational study conducted in Gambia between 1997 and 2003. The main purpose of their study was to compare the prognosis of HIV-1 and HIV-2 diseases. The authors state that there was no access to treatment in Gambia at the time of the study. Consequently, they described the natural history of the disease after the diagnosis of AIDS. However, at the time that their study began, highly-active antiretroviral therapy (HAART) was readily available in Europe, especially in the UK and the Netherlands. Therefore, we cannot understand how such an observational study could have been undertaken. Why did the authors observe their patients over 7 years without giving them HAART, the ‘life saving’ treatment? From a clinical point of view, offering a patient the best treatment available, after a diagnosis has been made, is a moral duty. From a scientific point of view, the CD4 cell count made at diagnosis at the time the patients were included in the study would have been sufficient. Everybody was aware that AIDS without treatment was a fatal disease.

Performance of the TruGene Human Immunodeficiency Virus Type 1 Genotyping Kit and OpenGene DNA Sequencing System on Clinical Samples Diluted to Approximately 100 Copies per Milliliter

ABSTRACT The TruGene human immunodeficiency virus type 1 (HIV-1) genotyping kit/OpenGene DNA sequencing system (Bayer HealthCare, Tarrytown, NY) reliably produced clinically acceptable resistance profiles for reverse transcriptase and protease inhibitors on patient samples diluted to ∼100 copies/ml following extraction with the QIAamp viral RNA minikit (QIAGEN Inc., Valencia, CA). One modification of the standard protocol was made to guarantee PCR amplification: a centrifugation step to concentrate virus was added before RNA extraction. For genotypic antiretroviral resistance testing, no significant differences in the identification and sensitivity of detection for codon mutations, base mutations, and multibase sites were found between the original and diluted samples.

Performance of the Abbott RealTime HCV Genotype II RUO Assay

ABSTRACT The Abbott RealTime HCV Genotype II RUO (research use only) assay was evaluated using the automated Abbott RealTime m2000 system. Concordance was 98% (81/83 samples) with samples previously typed by the Versant HCV Genotype 2.0 RUO system with manual extraction. The total assay time was reduced from 10.5 to 6.0 h and hands-on time from 13 to 4 min/patient sample.

Greater HIV testing after Veterans Health Administration policy change: the experience from a VA Medical Center in a high HIV prevalence area.

Abstract:Veterans Health Administration changed its HIV testing policy to remove requirements for written informed consent with pretest/posttest counseling and to make testing part of routine care in August 2009. HIV testing percentages were compared for 1-year periods before and after this change at our medical center located in Washington, DC, the city with the highest US HIV prevalence. After this policy change, HIV screening rose from 5.5% to 10.3% of persons in care with the majority of testing in outpatient settings and the greatest increase among veterans aged 61–70. Broadening of HIV testing has significance for HIV detection and prevention.

Candidemia outcomes not improved with statin use

Candidemia is an important cause of morbidity and mortality. As statins interfere with yeast membrane synthesis, we assessed whether use of statins during candidemia may cause differences in clinical outcomes. A retrospective review of 124 candidemia episodes during 2003-2008 in which all-cause and attributable mortality, length of stay and level of care were compared for patients who received and those who did not receive statins. A total of 124 candidemia events were observed involving 14 patients on statins and 110 without statins. Overall mortality in candidemia cases was 46%, but only 2% was attributed to candidemia. No differences were observed in clinical outcomes for the two groups of patients. During the last 2-year period of our study, there were higher rates of candidemia caused by non-C. albicans Candida spp., particularly those due to C. glabrata and C. parapsilosis. In conclusion, statin use during candidemia did not alter mortality, length of stay, or intensive care requirement of our patients, despite higher rates of non-C. albicans Candida species isolated during the last 2 years of our study.

Assessing Targeted Screening and Low Rates of HIV Testing

OBJECTIVES We assessed rates of HIV testing based on targeting patients with identified risk factors at the Veterans Affairs Medical Center in Washington, DC (VAMC-DC), where written informed consent along with pretest and posttest counseling had, until recently, been required by federal law. METHODS A cumulative retrospective review of the period 2000 through 2007 was conducted to assess the number of patients who were provided medical care at VAMC-DC, tested for HIV, and underwent confirmatory testing. Data on demographic characteristics and risks for HIV acquisition were also collected. RESULTS At VAMC-DC, 3.8% to 4.9% (mean=4.25%) of patients in care without known HIV infection underwent HIV screening annually. On average, HIV was confirmed at a yearly rate of 3.4% among those tested. During the study period, HIV prevalence ranged from 2.1% to 2.5%. Among patients receiving HIV care, 41.5% disclosed no risk factors for HIV acquisition. CONCLUSIONS Given that the HIV prevalence observed in this study was above 2% and that 41.5% of patients in care did not disclose any acquisition risks, targeted HIV screening has not been sufficient. HIV testing must be broadened and offered as part of routine medical care.

Implementation of Nurse-Initiated Rapid HIV Testing at High-Prevalence Primary Care Sites Within the US Veterans Affairs Health Care System

Nurse-initiated HIV rapid testing (NRT) increases testing/receipt of results compared with traditional testing. We implemented NRT in primary care clinics at 2 Veterans Affairs hospitals.At site 1, 2364 tests were conducted; 5 HIV positives were identified. At site 2, 2522 tests were conducted; 9 HIV positives were identified. Success varied across demographic/clinical strata.

Progress realized: Trends in HIV-1 viral load and CD4 cell count in a tertiary-care center from 1999 through 2011

Background HIV-1 RNA and CD4 cell counts are important parameters for HIV care. The objective of this study was to assess the overall trends in HIV-1 viral load and CD4 cell counts within our clinic. Methods Patients with at least one of each test performed by the Infectious Diseases Laboratory from 1999 through 2011 were included in this analysis. By adapting a novel statistical model, log10 HIV-1 RNA means were estimated by month, and log10-transformed HIV-1 RNA means were estimated by calendar year. Geometric means were calculated for CD4 cell counts by month and calendar year. Log10 HIV-1 RNA and CD4 cell count monthly means were also examined with polynomial regression. Results There were 1,814 individuals with approximately 25,000 paired tests over the 13-year observation period. Based on each patients final value of the year, the percentage of patients with viral loads below the lower limit of quantitation rose from 29% in 1999 to 72% in 2011, while the percentage with CD4 counts <200 cells/µL fell from 31% to 11%. On average annually, the mean HIV-1 RNA decreased by 86 copies/mL and the mean CD4 counts increased by 16 cells/µL. For the monthly means, the correlations (R2) from second-order polynomial regressions were 0.944 for log10 HIV-1 RNA and 0.840 for CD4 cell counts. Conclusions Marked improvements in HIV-1 RNA suppression and CD4 cell counts were achieved in a large inner-city population from 1999 through 2011. This success demonstrates that sustained viral control with improved immunologic status can be a realistic goal for most individuals in clinical care.

Risk Assessment for Healthcare Workers After a Sentinel Case of Rabies and Review of the Literature

BACKGROUND After a case of rabies, healthcare workers (HCWs) had fear of contagion from the infected patient. Although transmission of rabies to HCWs has never been documented, high-risk exposures theoretically include direct contact of broken skin and/or mucosa with saliva, tears, oropharyngeal secretions, cerebrospinal fluid, and neural tissue. Urine/kidney exposure posed a concern, as our patients renal transplant was identified as the infection source. METHODS Our risk assessment included (1) identification of exposed HCWs; (2) notification of HCWs; (3) risk assessment using a tool from the local health department; (4) supplemental screening for urine/kidney exposure; and (5) postexposure prophylaxis (PEP) when indicated. RESULTS A total of 222 HCWs including diverse hospital staff and medical trainees from university affiliates were evaluated. Risk screening was initiated within 2 hours of rabies confirmation, and 95% of HCWs were assessed within the first 8 days. There were 8 high-risk exposures related to broken skin contact or mucosal splash with the patients secretions, and 1 person without high-risk contact sought and received PEP outside our hospital. Nine HCWs (4%) received PEP with good tolerance. Due to fear of rabies transmission, additional HCWs without direct patient contact required counseling. There have been no secondary cases after our sentinel rabies patient. CONCLUSIONS Rabies exposure represents a major concern for HCWs and requires rapid, comprehensive risk screening and counseling of staff and timely PEP. Given the lack of human-to-human rabies transmission from our own experience and the literature, a conservative approach seems appropriate for providing PEP to HCWs.