Chronic subdural hematomas (CSDHs) and its management comprise a majority work in a neurosurgical specialty. The effectiveness of surgery is beyond doubt and sometimes even lifesaving in severe cases. However, the straightforward surgery is sometimes complicated by the associated comorbidities of the patient. Comorbidities in the form of coagulopathies secondary to chronic liver diseases, drugs (warfarin, ecosprin, clopidogrel), thrombocytopenia secondary to systemic illness are always a challenge to deal with in patients with CSDH. The authors encountered a patient with thrombocytopenia secondary to systemic HIV infection who presented with CSDH. Her coagulation profile was severe enough to preclude surgery. She was managed conservatively with tranexamic acid and responded well. The authors present the challenges they faced in the course of successful management of this patient.
Very-low-level viremia (VLLV) is a relatively new concept in the realm of human immunodeficiency virus (HIV) care. Newer generation assays are now able to detect plasma HIV RNA Viral Load (VL) levels as low as 20 copies/mL. The authors characterized patients with VLLV (VL between 20 and 50 copies/mL) in order to identify possible risk factors associated with virologic failure and poor clinical outcomes.
The authors reviewed 119 consecutive charts of patients with VLLV. Sociodemographic data were extracted and viral load and CD4 counts were trended over a 12 month period (February 2013-February 2014). Regression analysis was used to assess the role of different factors on virologic failure at 1 year.
Of the study participants with evaluable data (n = 100), the median age was 53 years (interquartile range: 43-57.5), 67% were nonwhite, 34% were women, 58% were smokers, 47% were alcoholics, 58% had a history of intravenous drug use, and 40% were coinfected with hepatitis C virus. More than half of the participants had 3 or more comorbidities and their HIV pill burden was high (more than 2 pills daily). After 12 months, 65 participants achieved undetectable viral load levels, whereas 15 experienced virologic failure (2 consecutive viral loads > 50 copies/mL) and the remaining 20 had persistent VLLV. In the virologic failure group, there was a predominance of white males (66%) with a significant number of comorbidities and pill burden. Univariate logistic regression suggested that there was a difference between the failure versus nonfailure groups in terms of race, ethnicity, and alcohol use. Multivariate regression with virological failure as the outcome suggested a trend only in terms of participant’s alcohol use.
Most patients with initial VLLV (70%) achieved virologic suppression at 1 year with no antiretroviral therapy changes. Thus, VLLV does not necessarily predict virologic failure and should not prompt more frequent clinic visits or antiretroviral regimen changes. Further research is needed in order to determine the predictors of virologic failure in this subset of patients and the clinicians’ attitude toward VLLV.
Mobile HIV counseling and testing (HCT) has been effective in reaching men, women, and adolescents in South Africa. However, there is limited understanding of effective mobile HCT programs utilizing tools like technology and edutainment to increase HIV counseling and testing rates. The authors examine data from the Shout-It-Now (S-N) program that uses such tools in South Africa.
The S-N program utilizes various forms of technology and ongoing telephonic counseling within a 6-step program of HIV testing and linkage-to-care support, and program data were analyzed over an 18-month period. Data were analyzed from women, men, and adolescent program participants. Summative statistics was conducted on participant registration, HIV risk assessment, and HIV testing profiles. HIV prevalence were estimated along with the related 95% confidence intervals using the Clopper-Pearson method.
Over an 18-month period, there were 72 220 program participants with high representation of men, women, and adolescents and 40% of the participants being men at each site. There were 3343 participants who tested HIV positive, and a higher proportion of women tested positive.
Integrating technology, quality assurance measures, and edutainment with mobile HCT has the potential to increase the number of those who test within communities. Research is needed to understand the effectiveness of this model in facilitating regular testing and linkage to care.
The use of alternative medicines, including herbs, is common among HIV-positive patients, even in those on antiretroviral treatment. Equisetum arvense, known as "horsetail," is mainly used for its diuretic properties. There are limited data about the pharmacological properties of this compound and the potential drug–herb interactions. The authors report 2 cases in which a possible drug–herb interaction may have led to virological breakthrough in patients who were maintained on the same regimen for many years, including lamivudine (3TC)/zidovudine (ZDV)/efavirenz (EFV) and emtricitabine (FTC)/tenofovir (TDF)/EFV, respectively. Therefore, a drug–herb interaction may be expected when these agents are taken concurrently. Until additional data are available, the authors advise clinicians to avoid this combination when possible.
Identification of broadly neutralizing antibodies (NAbs) generated during the course of HIV-1 infection is essential for effective HIV-1 vaccine design. The magnitude and breadth of neutralizing activity in the sera from 46 antiretroviral treatment–naive HIV-1 clade C-infected individuals was measured in a single round infection assay using TZM-bl cells and multisubtype panel of env-pseudotyped viruses. Higher levels of NAb response (NAb titer 500 to >40 000) were measured in these patients against tier 1 and tier 2 viruses. The average magnitude of the NAb responses of chronically infected individuals against heterologous viruses was consistently higher than the response observed from individuals with long-term nonprogressor (P = .086). To conclude, high titers of HIV-1 cross-neutralizing activity were observed in the sera from a subset of HIV-1-infected individuals in Chennai, India. Additional studies of the epitopes recognized by these antibodies may facilitate the discovery of an effective vaccine immunogen.
To examine the relationship between retention in continuous care and sustained viral suppression.
The authors retrospectively followed 653 persons who were virally suppressed and seeking care at an infectious disease clinic in Kentucky for an average of 6 years to determine the rates of retention in medical care (≥2 visits separated by ≥3 months within a 12-month period) and sustained viral suppression (<400 copies/mL). A generalized linear mixed model was used to determine an association between retention and suppression over time.
Approximately 61% of the study population were retained in continuous care and 75% had sustained viral suppression for all patient-years. Persons retained in care were 3 times the odds of sustaining viral suppression over time (P < .001).
Retention is essential to achieving and maintaining viral suppression. Strategies should be set in place that emphasize increasing the rates of retention, which in turn may increase the rates of suppression.
We examined the relationship between depression (symptom type, diagnostic severity, and change over time) and adherence to HIV antiretroviral therapy (ART) with data from 3 longitudinal studies (N = 1021) of patients starting ART in Uganda. The Patient Health Questionnaire was used to assess depressive symptoms (total score; somatic and cognitive subscales) and categorize severity level. At baseline, 9% had major depression and 30% had minor depression; 82% were adherent (reported no missed ART doses in the past 7 days) at month 6 and 85% at month 12. Controlling for demographic and medical covariates, multivariate random-effects logistic regression models revealed that change in depression was not related to adherence; however, baseline total depression symptoms and cognitive symptoms in particular as well as major and minor depression were significant predictors of adherence. These findings highlight the need for early identification and aggressive treatment of depression to optimize ART adherence.
Helminthic infection and HIV have been reported to coexist, particularly in sub-Saharan African patients living with HIV. Strongyloidiasis is one of the most common helminths, usually leading to cutaneous and gastrointestinal (GI) symptoms. In the immunocompromised host, this infection can lead to strongyloidiasis hyperinfection syndrome (SHS), not common in HIV-infected patients. Immune reconstitution inflammatory syndrome (IRIS) can follow the initiation of antiretroviral therapy (ART), with a variety of presentations. The authors present here a 32-year-old HIV-infected female who was recently diagnosed with AIDS, started ART, and recovered from SHS. Her upper endoscopy revealed severe duodenitis but no causal agent per biopsy or stool examination. After receiving symptomatic therapy, she showed improvement, a course of events that fit the diagnosis of GI-related IRIS.
The authors conducted a retrospective cohort study of unplanned care interruption (UCI) among adults initiating antiretroviral therapy (ART) from 2009 to 2011 in a Nigerian clinic. The authors used repeated measures regression to model the impact of UCI on CD4 count upon return to care and rate of CD4 change on ART. Among 2496 patients, 83% had 0, 15% had 1, and 2% had ≥2 UCIs. Mean baseline CD4 for those with 0, 1, or ≥2 UCIs was 228/cells/mm3, 355/cells/mm3, and 392/cells/mm3 (P < .0001), respectively. The UCI was associated with a 62 CD4 cells/mm3 decrease (95% confidence interval [CI]: –78 to –45) at next measurement. In months 1 to 6 on ART, patients with 0 UCI gained 10 cells/µL/mo (95% CI: 7-4). Those with 1 and ≥2 UCIs lost 2 and 5 cells/µL/mo (95% CI: –18 to 13 and –26 to 16). Patients with UCI did not recover from early CD4 losses associated with UCI. Preventing UCI is critical to maximize benefits of ART.
As part of the HPTN065 study in the Bronx, New York and Washington, the authors, we surveyed clinicians to assess for shifts in their practices and attitudes around HIV treatment and prevention. Antiretroviral therapy (ART)-prescribing clinicians at 39 HIV care sites were offered an anonymous Web-based survey at baseline (2010-2011) and at follow-up (2013). The 165 respondents at baseline and 141 respondents at follow-up had similar characteristics—almost 60% were female, median age was 47 years, two-thirds were physicians, and nearly 80% were HIV specialists. The percentage who reported recommending ART irrespective of CD4 count was higher at follow-up (15% versus 68%), as was the percentage who would initiate ART earlier for patients having unprotected sex with partners of unknown HIV status (64% versus 82%), and for those in HIV-discordant partnerships (75% versus 87%). In line with changing HIV treatment guidelines during 2010 to 2013, clinicians increasingly supported early ART for treatment and prevention.
Stigma shapes all aspects of HIV prevention and treatment, yet there are limited data on how HIV-infected youth and their families are affected by stigma in sub-Saharan Africa. The authors conducted a qualitative study using focus group discussions among 39 HIV-infected adolescents receiving care at HIV clinics in western Kenya and 53 caregivers of HIV-infected children. Participants felt that while knowledge and access to treatment were increasing, many community members still held negative and inaccurate views about HIV, including associating it with immorality and believing in transmission by casual interactions. Stigma was closely related to a loss of social and economic support but also included internalized negative feelings about oneself. Participants identified treatment-related impacts of stigma, including nonadherence, nondisclosure of status to child or others, and increased mental health problems. Qualitative inquiry also provided insights into how to measure and reduce stigma among affected individuals and families.
Pleural effusions typically present with nonspecific pulmonary complaints in the setting of either acute or chronic diseases. In the general population, these illnesses include congestive heart failure, infection, and malignancy. However, in people living with HIV/AIDS (PLWHA), pleural effusions often result from opportunistic infections and AIDS-defining malignancies, such as Kaposi sarcoma and non-Hodgkin lymphoma. Since the introduction of highly active antiretroviral therapy, there has been a decline in the frequency of AIDS-defining opportunistic infections and AIDS-defining cancers and an increase in certain non-AIDS-defining malignancies including lung cancer. Throughout this period, longer life expectancy in PLWHA has contributed to an increased risk of those chronic diseases that can result in pleural effusions. This case describes an HIV-infected man who was an active cigarette smoker and alcoholic and who presented with a large pleural effusion of uncertain etiology. The authors review several important noncardiac risk factors associated with pleural effusions in PLWHA. The authors also emphasize the importance of obtaining a detailed medical history and the use of appropriate imaging and laboratory tests in order to identify an underlying cause and to provide optimal treatment.
Patients with perinatally acquired HIV may be at risk for the development of age-related non-AIDS diseases. The primary aim of this study was to describe patterns of systemic hypertension among a cohort of adults (≥18 years) with perinatally acquired HIV. A retrospective cohort study was conducted among adults (≥18 years) with perinatally acquired HIV infection. Primary outcomes included documentation of systemic hypertension as well as several additional non-AIDS-associated illnesses. Systemic hypertension incidence rates and rate ratios (RRs) were calculated among groups aged ≥18 and <18 years at the time of hypertension diagnosis. The overall prevalence of hypertension in the cohort (N = 109) was 26.6%, and the incidence rate of hypertension was significantly higher among those aged ≥18 years compared to those who are aged <18 years at the time of diagnosis (RR: 10.0, CI: 7.29-13.71). By multivariable analysis, only coexisting renal disease was associated with an increased risk of hypertension diagnosis.
In the United States, men who have sex with men (MSM) are known to disproportionately have HIV. The authors sought to describe the acceptability of providing at-home dried blood spot specimen collection kits for HIV testing among MSM.
Between August 2010 and December 2010, the authors recruited Internet-using, HIV-negative or -unknown MSM to participate in a 12-month study of behavioral risks. Eligible participants were mailed an at-home HIV test.
Of the 896 men who were sent a test kit, 735 (82%) returned the kit. Returning a test kit was significantly associated with race (P = .002), highest level of education (P = .012), and annual income (P = .026). The adjusted odds of black, non-Hispanic men returning a test kit were about half of the odds of white, non-Hispanic men returning a test kit (adjusted odds ratios: 0.49; 95% confidence intervals: 0.31-0.78).
Men who have sex with men are willing to provide biological specimens as part of an Internet-based HIV prevention study.
The objective of this report was to assess Georgia’s progress toward Joint United Nations Programme on HIV/AIDS 90-90-90 targets over the period between 2011 and 2015. The number of HIV-positive persons was estimated using Spectrum software. Number of persons diagnosed, on antiretroviral therapy (ART) and virally suppressed were quantified using data from the national AIDS health information system. By the end of 2015, out of the estimated 7100 persons living with HIV, 62% were diagnosed, 38% were on ART, and 32% were virally suppressed. There were improvements in each stage of cascade from 2011 to 2015: the proportion of diagnosed persons increased from 46% to 61%, ART coverage among diagnosed persons increased from 46% to 62%, and the proportion of virally suppressed patients among those on ART increased from 74% to 85%. Despite the progress, additional efforts are needed to reach the 90-90-90 targets. Reducing the number of people living with undiagnosed HIV will be critical for achieving goals.
Racial and ethnic disparities in viral load suppression (VLS) have been well documented among people living with HIV (PLWH). The authors hypothesized that a contemporary analytic technique could reveal factors underlying these disparities and provide more explanatory power than broad stereotypes. Classification and regression tree analysis was used to detect factors associated with VLS among 11 419 adult PLWH receiving treatment from 186 New York State HIV clinics in 2013. A total of 8885 (77.8%) patients were virally suppressed. The algorithm identified 8 mutually exclusive subgroups characterized by age, housing stability, drug use, and insurance status but neither race nor ethnicity. Our findings suggest that racial and ethnic disparities in VLS exist but likely reflect underlying social and behavioral determinants of health.
HIV has disproportionately affected economically vulnerable populations. HIV medical care, including antiretroviral therapy, successfully restores physical health but can be insufficient to achieve social and economic health. It may therefore be necessary to offer innovative economic support programs such as providing business training and microcredit tailored to people living with HIV/AIDS. However, microfinance institutions have shown reluctance to reach out to HIV-infected individuals, resulting in nongovernment and HIV care organizations providing these services. The authors investigate the baseline characteristics of a sample of medically stable clients in HIV care who are eligible for microcredit loans and evaluate their business and financial needs; the authors also analyze their repayment pattern and how their socioeconomic status changes after receipt of the program. The authors find that there is a significant unmet need for business capital for the sample under investigation, pointing toward the potentially beneficial role of providing microfinance and business training for clients in HIV care. HIV clients participating in the loans show high rates of repayment, and significant increases in (disposable) income, as well as profits and savings. The authors therefore encourage other HIV care providers to consider providing their clients with such loans.
The US treatment guidelines recommend Pneumocystis jiroveci pneumonia (PCP) prophylaxis for all HIV-infected persons with a CD4 count <200 cells/mm3 (ie, eligible for PCP prophylaxis). However, some studies suggest PCP prophylaxis may be unnecessary in virally suppressed patients. Using national data of HIV-infected adults receiving medical care in the United States during 2009 to 2012, the authors assessed the weighted percentage of eligible patients who were prescribed PCP prophylaxis and the independent association between PCP prophylaxis prescription and viral suppression. Overall, 81% of eligible patients were prescribed PCP prophylaxis. Virally suppressed eligible patients were less likely to be prescribed PCP prophylaxis (prevalence ratio: 0.84; 95% confidence interval: 0.80-0.89). Although guidelines recommend PCP prophylaxis for all eligible patients, some HIV care providers might not prescribe PCP prophylaxis to virally suppressed patients. Additional data on the risk for PCP among virally suppressed patients are needed to clarify this controversy.
Social support has been noted to improve health outcomes for individuals with HIV. Understanding how neighborhoods contribute to feelings of social support is beneficial to create environments where populations with HIV can be supported. This study assessed the relationship between neighborhood perceptions and social support with HIV management. A total of 201 individuals were recruited; individuals with HIV, 18 years or older, who were eligible to participate in the 2-hour interview. Psychiatric diagnostic interviews were conducted alongside assessments of social support and neighborhood perceptions; biomedical markers were abstracted from medical records. Correlations and linear regression analyses were performed to assess relationships between social support and neighborhood perceptions with HIV management biomarkers. The majority of the sample was male (68.8%) and African American (72.3%), with a mean age of 43.1 years. Overall, 78% were receiving combination antiretroviral therapy (cART) prescriptions, with 69% being virally suppressed. Fear of neighborhood activities was independently associated with receiving current cART. Reports of social support and neighborhood perceptions were highly correlated. Findings suggest that supportive home environments likely would improve perceptions of social support.
Since 2006, numerous testing initiatives have been launched across the United States to increase the number of individuals who know their HIV status. These initiatives are often venue based and reported in a variety of settings. However, the effectiveness of these initiatives has not been evaluated to determine if patients were identified earlier in the course of disease or would not have been otherwise tested. In 2010, a publicly funded teaching hospital implemented an electronic medical record prompt to improve the rate of routine HIV screening and diagnosis, focusing on primary care office visits. Both sex and CD4 count were found to be significantly related to being newly diagnosed after the intervention. Routine testing in primary care is an effective strategy to diagnose patients earlier in disease progression, particularly men who might otherwise not be tested and thus would remain undiagnosed until developing symptoms from advanced disease.
Preexposure prophylaxis (PrEP) for HIV has the potential to reduce HIV incidence in highly affected areas. The Southeastern United States is disproportionately impacted by HIV, and 3 counties in South Florida have the highest incidence of new HIV infections in the United States. This study explored the feasibility, acceptability, and uptake of PrEP in South Florida. Focus groups consisting of providers, administrators, and case managers at HIV-servicing community health centers and federally qualified health centers in South Florida reported broad support but low implementation of PrEP. Generally, participants indicated that the centers were appropriate locations for implementation. However, practical concerns and perceived limitations due to financial, insurance, and immigration status of those who would potentially benefit from the intervention were widely reported. Addressing provider concerns appears necessary for successful expansion of PrEP implementation in highly impacted areas such as South Florida.
It has been previously shown that patients may present for multiple health issues in the years preceding their initial HIV diagnosis. This retrospective cohort study analyzed the data of patients with a new HIV diagnosis, at Ochsner Health System between January 1, 2011, and December 31, 2012. The primary end point was missed opportunities, the number of healthcare visits these patients made in the 2 years prior to being diagnosed with HIV. The 125 patients in the study cohort had 649 healthcare visits during which an HIV test was not performed. These missed opportunities are the key to capturing the undiagnosed and unaware HIV-positive individual. Primary care is an ideal setting to conduct HIV testing for those who have access to regular health care. However, nontraditional providers should also be encouraged to conduct HIV testing regardless of their ability to provide treatment because evidence shows that knowledge of the diagnosis may change behavior.
Antiretroviral Therapy (ART) has transformed life threatening HIV/AIDS scenario into chronic manageable disease.
In this cross-sectional, 409 People Living with Human Immunodeficiency Virus (PLHIV) aged ≥ 18 years, who were on ART, were assessed regarding the adherence to ART and factors affecting adherence using semi-structured questionnaire. The association between factors affecting adherence and the level of adherence were analyzed using multiple logistic regression model and odds ratio (OR) with 95% confidence intervals (CI) were reported.
Among 409 PLHIV, 70.4% showed adherence to ART (≥95%). Univariate analysis yielded many factor associated with adherence (P < 0.05). However, on multivariate analysis, PLHIV who do not forget to take ART and not consuming alcohol were the factors consistent with adherence to ART (P < 0.05).
Regular patient education and counseling regarding the usage of memory aids and abstinence from alcohol could be useful for adherence and long term success of ART among PLHIV.
Provision of antiretroviral therapy in resource limited settings has put pressure on the available infrastructure.
The study examined patients’ adherence to Doctor’s appointment attendance after an intervention changing the model of care and factors that predicted adherence.
Observational study was carried out over four years. The model of care was changed in the last year and the effect assessed. SPSS version 15.0 was used for analysis. Predictors of adherence were determined using logistic regression model.
Over half 148 (59.7%) of the patients were females, with a mean age of 40.4±8.8 years and baseline CD4 cells of 143.5±92.7cells/microliters. "Adherence" rates were 51.3% in 2007, 35.9% in 2008 and 14.9% in 2009 giving patients’ average adherence to Doctor’s appointment attendance of 34.03%. Intervention changing the model of care in 2010 recorded an adherence rate of 93.1%.
The change in model of care greatly improved patients’ "adherence". Patients’ knowledge of management, adherence, and smoking and drinking habits were identified as statistically significant predictors of adherence.
The purpose of this study is to assess postmarketing safety and tolerability of Stribild (elvitegravir [EVG]/cobicistat [COBI]/tenofovir disoproxil fumarate [TDF]/emtricitabine [FTC]).
A retrospective, pharmacoepidemiologic study in 2 outpatient HIV clinics in the Southeast United States was conducted among adults receiving EVG/COBI/TDF/FTC. We evaluated incidence and treatment-related adverse events, including change in serum creatinine (SCr).
Patients were primarily treatment experienced (n = 173, 60%), African American (n = 210, 73%), and males (n = 187, 65%). One hundred ninety-five (68%) patients had any increase in SCr, and 65 (23%) had an increase of ≥0.3 mg/dL. Mean SCr change from baseline to peak was 0.2 mg/dL. Being treatment experienced (odds ratio [OR] = 2.21, 95% confidence interval [CI]: 1.12-4.38) was associated with SCr ≥0.3 mg/dL, while body mass index ≥30 kg/m2 (OR = 0.41, 95% CI: 0.18-0.93) was protective. Twenty (7%) patients discontinued therapy, 3 due to acute kidney injury.
Our results demonstrate limited adverse events and low discontinuation rates associated with EVG/COBI/TDF/FTC.
Without antiretroviral therapy (ART), approximately one-half of HIV-infected infants will die by two years. In 2010, the World Health Organization (WHO) recommended that all HIV-infected infants < 24 months be initiated on ART regardless of their clinical/immunologic status. However, there remains little published data detailing cohorts of infants on ART in Sub-Saharan Africa. This study describes baseline characteristics and 12 month outcomes of a cohort of HIV-infected children < 24 months of age at pediatric HIV centers in Mwanza and Mbeya, Tanzania.
Retrospective chart review. Inclusion criteria: children < 24 months of age, initiated on ART at Baylor Children s Foundation Tanzania clinics, between March–December 2011.
Our cohort of HIV infected children < 24 months initiated on ART did well clinically at 12 month outcomes despite being severely immunocompromised and malnourished at baseline. Nevirapine based regimens had good 12 month clinical outcomes, regardless of maternal exposure. Loss to follow-up rate was high for our cohort, demonstrating the need to develop strong mechanisms to counteract this.
We evaluated the efficacy of a brief motivational intervention (MI) counseling in reducing alcohol consumption among persons living with HIV/AIDS in Kampala, Uganda. Persons living with HIV/AIDS with Alcohol Use Disorders Identification Tool (AUDIT) score ≥3 points were randomized to either standardized positive prevention counseling alone or in combination with alcohol brief MI counseling. The mean change in AUDIT-C scores over 6 months was compared by treatment arm. The mean (standard deviation [SD]) AUDIT-C scores were 6.3 (2.3) and 6.8 (2.3) for control and MI arms (P = .1) at baseline, respectively, and change in mean AUDIT-C score was not statistically different between arms over the 6 months (P = .8). However, there was a statistically significant decrease in mean AUDIT-C score (–1.10; 95% confidence interval: –2.19 to –0.02, P = .046) among women in the MI arm. There was a nondifferential reduction in alcohol consumption overall, but MI appeared effective among women only. Studies with more than 1 counseling session and evaluation of gender differences in treatment response are needed.
Streptococcus pneumoniae infection is a predominant cause of bacterial infection in HIV-infected individuals. However, reported rates of pneumococcal vaccination with 23-valent polysaccharide vaccine (PPV23) are variable. We evaluated uptake of PPV23 in patients diagnosed with HIV between 1996 and 2012 (n = 507) in the United States Air Force, a centralized HIV program with free access to care including vaccines and medications. A total of 411 (81.1%) patients received at least 1 PPV23 dose. The PPV23 vaccination within 1 year of diagnosis was greater for those diagnosed between 2004 and 2012 (n = 184, 86%) compared with 1996 to 2003 (n = 104, 56.5%; P < .001). For those with ≥6 years of follow-up, receipt of a second recommended PPV23 dose was greater for those diagnosed between 1996 and 2003 (n = 52, 57.8%) compared with 2004 to 2012 (n = 9, 28.1%; P = .004). Although first PPV23 vaccination was high in recent years, process improvement efforts are underway to overcome barriers and improve uptake of pneumococcal vaccines in our program.
Tobacco use has emerged as a leading cause of death among persons living with HIV (PLWH) who smoke cigarettes. In contrast to the general population where smoking prevalence in men exceeds that in women, large surveys have shown similar smoking rates among male and female PLWH. There are important behavioral and biological differences between male and female smokers, but little is known about the relationships between tobacco use and gender in PLWH. Herein, the authors present a detailed examination of gender differences in smokers living with HIV (N = 267; 54% male, 46% female) recruited in 2 tobacco treatment trials. The authors found higher rates of heavy smoking and other substance use in men. Women were more likely to have used pharmacotherapy during quit attempts. Asthma rates were markedly higher in female smokers. There were no significant differences in a range of psychobehavioral domains or in cessation rates between male and female smokers living with HIV.
Physical function limitations have been associated with poor health outcomes, which have a negative impact on quality of life of older individuals. This study examined the association between depression, viral load, and acculturation with physical function among Latino men living with HIV. A secondary data analysis was performed using a cross-sectional data of 146 Latino immigrant men living with HIV in New York City and Washington, DC. Physical function was measured using the Short-Form Health Survey (SF-12). Uncontrolled HIV infection and depression were associated with worse physical function, thus implying the importance of adequate health care to address these conditions. Preserving physical function should start during middle adulthood, particularly among people living with HIV because of their greater risk of developing age-related challenges such as depression, diabetes, cardiovascular diseases among others. This study informs future interventions to preserve physical function and achieve the goal of successful aging.
The U.S. Centers for Disease Control and Prevention and the U.S. Preventive Services Task Force issued HIV testing recommendations, encouraging physicians to routinely test all adult patients for HIV. Studies have found that not all physicians are abiding by these guidelines, but that physician recommendations for HIV testing could encourage patients to get tested. Our study sought to determine physician preferences for a physician-targeted campaign to encourage them to offer HIV tests to their patients. The study took place across 19 publicly-funded community health centers. A web-based survey was sent to primary care physicians, assessing their preferences for physician-targeted HIV testing campaign elements. Response frequencies were calculated for each element. 175 physicians participated. Campaign elements were divided into "HIV Testing Information," "Communication Tools," and "Promotion Strategies." Physicians selected receiving a copy of the latest HIV testing recommendations, having patients ask for the HIV test, and receiving an EMR alert for HIV testing as their top elements for each category, respectively. An effective physician HIV testing campaign should include information about HIV testing recommendations, proof of patient receptiveness to HIV testing, and strategies to prompt HIV testing conversations. A multi-faceted approach combining patient and physician prompts to discuss HIV testing might be the most effective method to improve HIV testing rates.
In many resource-poor settings such as Peru, children affected by HIV have a high prevalence of neurodevelopmental delays (NDDs) and remain excluded from adequate treatment.
Community health workers (CHWs) administered NDD screening instruments to assess child development and associated caregiver and household factors in 14 HIV-affected parent–child dyads. Focus group discussion with caregivers was conducted to explore their needs and behaviors around early child stimulation and to assess their perceptions of the screening experience.
Over 70% of the children had abnormal classification in at least 1 (out of 5) developmental domains according to Ages and States Questionnaire–provided cutoff scores. Caregiver depression and stress were associated with abnormal development as were some parenting behavior factors. Knowledge about child development was low. Caregivers felt testing and discussing results with a CHW were very insightful. Reported caregiver behavior differed between caregivers with HIV-infected children and those with uninfected children.
Taken together, these exploratory quantitative data suggest that parenting behaviors associated with low child development scores may be modifiable and that community-based testing is well received and informative to these HIV-infected caregivers.
To determine the socioeconomic impacts among HIV-infected persons in Sudan and examine whether there are significant variations in coping strategies between infected men and women, a primary survey was conducted among infected persons (n = 555). Discriminant function was used to analyze the data. We found significant variation in the coping strategies (<.001). HIV/AIDS impacts were more critical for women. Infected people have 3 alternatives in coping with the changes in their income and expenditure, that is, borrow, utilize savings, or sell assets. Policy makers should consider economic information in planning health care to mitigate the impacts and remove the gender gap.
We sought to characterize recent cases of toxic epidermal necrolysis (TEN) in HIV-infected patients at San Francisco General Hospital (SFGH), a large HIV referral center.
This was a retrospective analysis of HIV-infected patients diagnosed with TEN from January 2001 to May 2014 at SFGH.
Ten cases of TEN were identified, 50% of which occurred in HIV-infected individuals. Among the HIV-associated cases, causative agents were trimethoprim–sulfamethoxazole (TMP-SMX; n = 2), atovaquone, clindamycin, and fluconazole. No antiretroviral agents were implicated.
Although limited by small sample size, our experience is reflective of the well-recognized increased incidence of TEN in HIV-positive patients and suggests that antimicrobial agents, particularly TMP-SMX, are the most common causative agents in this population. As 3 of the 5 HIV-associated TEN cases were caused by potentially inappropriate or unnecessary use of antibiotics, our experience highlights the importance of judicious use of systemic medications in populations susceptible to severe adverse drug reactions.
This study was conducted on patients with thalassemia and HIV-infected patients to determine the frequency of diarrheagenic Escherichia coli in Kerman, Iran. We analyzed 68 and 49 E coli isolates isolated from healthy fecal samples of patients with thalassemia and HIV-infected patients, respectively. The E coli isolates were studied using a multiplex polymerase chain reaction to identify the enterotoxigenic E coli (ETEC), enterohemorrhagic E coli (EHEC), and enteropathogenic E coli (EPEC) groups. Statistical analysis was carried out to determine the correlation of diarrheagenic E coli between HIV-infected patients and patients with thalassemia using Stata 11.2 software. The frequency of having at least 1 diarrheagenic E coli was more common in patients with thalassemia (67.64%) than in HIV-infected patients (57.14%; P = .25), including ETEC (67.64% versus 57.14%), EHEC (33.82% versus 26.53%), and EPEC (19.11% versus 16.32%). The results of this study indicate that ETEC, EHEC, and EPEC pathotypes are widespread among diarrheagenic E coli isolates in patients with thalassemia and HIV-infected patients.
HIV testing and linkage to care are critical first steps along the care continuum. Targeted efforts are needed in the South to achieve the goals of the National HIV/AIDS Strategy, and qualitative examination of testing and linkage to care from the perspective of professionals in the field can provide nuanced insight into the strengths and limitations of a care system to inform improvement efforts. These issues are explored in North Carolina (NC), with potential applicability to other Southern states.
Twenty-one interviews were conducted with professionals in the HIV prevention and care systems in NC. Interviews were analyzed for emergent themes.
Individuals’ access barriers, aspects of clinics and clinical care, challenges for community-based organizations, stigma, and the role of the NC Department of Health and Human Services were identified as themes affecting testing and linkage.
These findings can inform efforts to address HIV testing and linkage to care in NC. This approach may provide beneficial insight for other systems of care.
Suicidality has rarely been studied in HIV-infected patients in sub-Saharan Africa. This study explored suicidal behavior in a clinic sample of people living with HIV, in Nigeria.
Consecutive patients were interviewed using the Composite International Diagnostic Interview (CIDI-10.0) and the World Health Organization Quality of Life (WHO-QOL-HIV-BREF). Associations of suicidal behavior were explored using logistic regression models.
In this sample of 828 patients (71% female, mean age 41.3 ± 10 years), prevalence of suicidal behaviors were 15.1%, 5.8%, and 3.9% for suicidal ideation, plans, and attempts, respectively. Women were more likely than men to report suicidal ideation (odds ratio 1.7; 95% confidence interval 1.05-2.64). Depression and/or anxiety disorder was associated with increased odds of all suicidal behaviors. Suicidal behavior was associated with significantly lower overall and domain scores on the WHO-QOL.
Suicidal behaviors were common and significantly associated with the presence of mental disorders and lower quality of life.
Retention in HIV care is critical to decrease disease-related mortality and morbidity and achieve national benchmarks. However, a myriad of barriers and facilitators impact retention in care; these can be understood within the social–ecological model. To elucidate the unique factors that impact consistent HIV care engagement, a qualitative case study was conducted in North Carolina to examine the barriers and facilitators to retain and reengage HIV clients in care. HIV professionals (n = 21) from a variety of health care settings across the state participated in interviews that were transcribed and analyzed for emergent themes. Respondents described barriers to care at all levels within the HIV prevention and care system including intrapersonal, interpersonal, institutional, community, and public policy. Participants also described recent statewide initiatives with the potential to improve care engagement. Results from this study may assist other states with similar challenges to identify needed programs and priorities to optimize client retention in HIV care.
In Asian concentrated HIV epidemics, data on coinfection of sexually transmitted infections (STIs) among HIV-positive individuals are limited. The authors measured the prevalence of Chlamydia trachomatis (CT), Neisseria gonorrhea (NG), and syphilis, and their correlates among 319 HIV-positive individuals in Kathmandu, Nepal. The authors tested blood samples for syphilis and urine samples for CT and NG. Overall, 17 (5.3%) participants had at least 1 STI (CT: 1.3%, NG: 2.8%, and syphilis: 1.2%). Of 226 participants who had sex in past 6 months, 51.3% did not always use condoms. Older (aged 35-60 years) participants were more likely (adjusted odds ratio [AOR] = 3.83; 95% confidence interval [CI] = 1.19-12.33; P = .024) and those who were currently married (AOR = 0.30; 95% CI = 0.09-0.97; P = .046) or on antiretroviral therapy (AOR = 0.21; 95% CI = 0.06-0.71; P = .012) were less likely to have at least 1 STI. Our results suggest the need to strengthen the efforts to screen and treat STIs and to promote safer sexual practices among Nepalese HIV-positive individuals.
Improved understanding of cholesterol levels in HIV- and hepatitis C virus (HCV)-infected persons in Argentina will guide optimal antiretroviral therapy. The authors conducted a cross-sectional study in Argentina to describe associations between HIV, HCV, and cholesterol. Of the 202 participants, 21 were HIV infected, 15 were HCV infected, 46 were HIV/HCV coinfected, and 120 were HIV/HCV uninfected. HIV/HCV-uninfected participants had the highest total cholesterol (TC) and low-density lipoprotein (LDL) levels. Multivariate modeling revealed that HIV/HCV-coinfected patients had the lowest TC levels (–28.7 mg/dL, P < .001) compared to the HIV/HCV-uninfected reference group. Hepatitis C virus and HIV/HCV coinfection were associated with lower LDL levels (–21.4 mg/dL, P = .001 and –20.3 mg/dL, P < .0001, respectively). HIV and HIV/HCV coinfection, but not HCV alone, were associated with lower high-density lipoprotein levels (–9.1 mg/dL, P = .0008 and –6.8 mg/dL, P = .0006, respectively). Further study is needed to examine whether the more favorable lipid profile observed in HIV/HCV-coinfected persons is associated with a reduction in cardiovascular risk.
Retention in care is a major challenge for HIV treatment programs, including in rural and in resource-limited settings. To help reduce loss to follow-up (LTFU) for HIV-infected patients new to care in rural Ethiopia, 142 patients were assigned 1 of 13 trained community health support workers (CHSWs) who were HIV positive and from the same neighborhood/village. The CHSWs provided HIV and health education, counseling/social support, and facilitated communication with the HIV clinics. With 7 deaths and 3 transfers, the 12-month retention rate was 94% (95% CI = 89%-97%), and no client was LTFU in the project. Between enrollment and 12 months, clients had significant (P ≤ .001) improvements in HIV knowledge (17% increase), physical and mental quality of life (81% and 21% increase), internalized stigma (97% decrease), and perceived social support (24% increase). In rural and resource-limited settings, community-based CHSW programs can complement facility-based care in reducing LTFU and improving positive outcomes for HIV-infected people who enter care.
The objectives of this study were to determine if a video improved HIV/AIDS and HIV testing knowledge among a global sample of Internet users, to discern if this improvement was the same for English and Spanish speakers, and to ascertain if the video was efficacious for those with lower health literacy. A worldwide sample of English- or Spanish-speaking Internet users was solicited. Participants completed a 25-item questionnaire to assess their HIV/AIDS and HIV testing knowledge before and after watching the video. Mean scores on the questionnaire improved after watching the video for both English speakers (after: 19.6 versus before: 16.4; = 3.2; 95% confidence interval [CI]: 2.8-3.5) and Spanish speakers (20.7 versus 17.3; = 3.4; 95% CI: 3.0-3.8). There was no difference in improvement of scores between English and Spanish speakers ( = –0.24; 95% CI: –0.79 to 0.31), and this video was equally efficacious for those with lower and higher health literacy skills.
Evidence-based guidelines have long recommended that HIV care providers deliver HIV transmission risk-reduction (RR) services, but recent data are needed to assess their adoption.
The authors surveyed a probability sample of 1234 US HIV care providers on delivery of 9 sexual behavior– and 7 substance use–related HIV transmission RR services and created an indicator of "adequate" delivery of services in each area, defined as performing approximately 70% or more of applicable services.
Providers were most likely to encourage patients to disclose HIV status to all partners since HIV diagnosis (81%) and least likely to ask about disclosure to new sex and drug injection partners at follow-up visits (both 41%). Adequate delivery of sexual behavior– and substance use–related RR services was low (37% and 43%, respectively).
The majority of US HIV care providers may need additional support to improve delivery of comprehensive HIV transmission RR services.
Desires to have children are not lessened by a woman’s HIV status. Couples may lack information to conceive safely, and men may be especially uninformed. This study examined reproductive intentions, practices, and attitudes among men in HIV-infected couples, including attitudes regarding the perceived risk of vertical and horizontal transmission, safer conception, and preconception planning.
Men (n = 12) in HIV-infected couples were interviewed regarding reproductive intentions, attitudes, and knowledge and qualitative assessments were coded for dominant themes.
Themes primarily addressed concerns about the health of the baby, men’s involvement in pregnancy, safer conception, concerns about HIV transmission and antiretroviral therapy, and HIV infection. Men lacked information on safer conception and newer HIV prevention strategies, such as pre-exposure prophylaxis (PrEP).
Gaps in knowledge regarding preconception practices among men in HIV-infected couples were identified. Results highlight men’s desire for involvement in preconception planning, and opportunities for providers to facilitate this practice and to increase patient education and the use of PrEP are discussed.
Elimination of pediatric HIV requires a robust program for the prevention of mother-to-child transmission (PMTCT). The goal of this study was to assess the implementation of these services in Cambodia.
This prospective study was conducted in Bantey Meanchey at 2 sites. Staff reviewed daily clinic and laboratory registration logs to gather data on PMTCT service access among antenatal women.
A total of 12 140 pregnant women received antenatal care. Only 4034 (33.2%) received pre-HIV test counseling. Of which 3407 (84.5%) received an HIV test. Eighteen (94.7%) of 19 women testing HIV-seropositive received triple-combination antiretroviral (ARV) medication. Fifteen HIV-exposed infants were delivered during the study. One infant tested HIV positive and is on ARV medication.
Acceptance for HIV testing was high among women who received pretest counseling. An increase in the number of counselors may improve the rates of HIV testing. Follow-up mechanisms targeting mother–baby pairs should focus on increasing timely service uptake in the public sector.
Despite the success of prevention of mother-to-child transmission programs, transition to care in the postpartum period is vulnerable to being lost to care.
The authors performed a 2-year retrospective study of postpartum HIV-infected patients at Komfo Anokye Teaching Hospital in Kumasi, Ghana. The outcome was classified as optimal follow-up, suboptimal follow-up, and loss to follow-up (LTFU). Univariate and multivariate analyses were used to identify factors associated with optimal retention.
Follow-up was optimal in 66%, suboptimal in 16%, and LTFU in 18% of patients. The rate of LTFU was 22% among women diagnosed at pregnancy and 13% among those with known HIV diagnosis (P = .078). Adherence counseling (odds ratio [OR] 5.0, confidence interval [CI] 1.6-15.7; P = .006) and family planning (FP; OR 2.3, CI 1.0-5.3; P = .041) were predictive of optimal follow-up.
At 1 year, only two-thirds of postpartum women remained in care. Investigating barriers to adherence counseling and FP may impact engagement in care among HIV-infected women.
HIV rates are disproportionately higher in the incarcerated compared to the general population. Unfortunately, HIV sero-positive inmates report perceived discrimination and missed antiretroviral doses. Correctional facility nursing competency in HIV management may mitigate these concerns. Using validated knowledge instruments, the authors measured baseline HIV knowledge in correctional facility nurses from 3 correctional facilities in Alberta, Canada, and quantified changes after a targeted educational workshop. Basic HIV knowledge increased significantly, whereas perceived need for further HIV education significantly decreased postintervention. This study demonstrates that correctional facility nurses may not receive ideal HIV education during employment and that targeted HIV workshops can significantly increase knowledge and confidence when caring for affected individuals.
Poor treatment adherence is a main barrier for effective antiretroviral therapy (ART) globally. HIV-related knowledge may affect understanding and utilization of HIV medical information, hence limited health literacy is a known barrier to treatment adherence.
A cross-sectional study included 494 HIV-infected individuals from the Bissau HIV Cohort in Guinea-Bissau. They completed a questionnaire designed for assessment of adherence and HIV-related knowledge.
A majority were female, 41% were illiterate, 25% did not take the medicine during the last 4 days, and 23% skipped their medicine during weekends. The most frequent reasons for not taking medicine were simply forgetting, side effects, lack of food, and being too ill to attend the clinic. Nonadherent patients had a lower level of HIV-related knowledge.
Main barriers for nonadherence were side effects, food insecurity, and simply forgetting. Lack of HIV-related knowledge about ART and HIV may be a barrier to nonadherence.
To evaluate the implementation of community-based voluntary HIV counseling and testing (CBVCT) in the Eastern Caribbean.
A total of 9782 unique HIV testing events performed through a national program of CBVCT in Antigua and Barbuda (2009-2012) were analyzed. The authors describe testers’ demographic characteristics and assess demographic (education, housing, marital status, nationality, and age) and sexual exposure (partner gender, transactional sex, and multiple partners) factors associated with testing HIV-positivity and with condom use.
Older men and men having sex with women and women with higher education, of Antiguan nationality, and having sex with men were less likely to test positive for HIV. Younger, educated, and unmarried men and women with multiple partners were more likely to report using condoms.
The CBVCT model can be successfully implemented in Eastern Caribbean. Demographic differences persist in HIV testing, risk behavior, and infection among vulnerable populations and should be considered in HIV prevention intervention design.
Antiretroviral therapy (ART) has increased life expectancy of HIV/AIDS patients, but the quality of life (QOL) still remains the same.
In this cross-sectional study, 356 people living with HIV (PLHIV) were interviewed to assess their QOL using WHOQOL-HIV BREF questionnaire. The association between QOL with sociodemographic, clinical and cohabitation status of the participants was tested using ANOVA and Student t-test, and p value < .05 was considered statistically significant.
Physical domain of QOL showed maximum score of 16.4, while a minimum score of 12.2 was seen in social relationship domain. Participants with higher socioeconomic status (SES) and self-motivated to take ART had shown better scores across all the domains of QOL (p < .05).
In our study, quality of life was high among males, younger patients, married participants, higher socioeconomic status, longer duration of ART, self-motivation to take ART, absence of opportunistic infection, and with higher CD4 count.
Increasing the proportion of HIV-positive individuals who link promptly to and are retained in care remains challenging in sub-Saharan Africa, but little evidence is available from the provider perspective. In 4 Ethiopian health facilities, we (1) interviewed providers and peer educators about their perceptions of service delivery- and patient-level barriers and (2) observed provider–patient interactions to characterize content and interpersonal aspects of counseling. In interviews, providers and peer educators demonstrated empathy and identified nonacceptance of HIV status, anticipated stigma from unintended disclosure, and fear of antiretroviral therapy as patient barriers, and brusque counseling and insufficient counseling at provider-initiated testing sites as service delivery-related. However, observations from the same clinics showed that providers often failed to elicit patients’ barriers to retention, making it unlikely these would be addressed during counseling. Training is needed to improve interpersonal aspects of counseling and ensure providers elicit and address barriers to HIV care experienced by patients.
The Health Resources and Services Administration requires that jurisdictions receiving Ryan White (RW) funding justify need, set priorities, and provide allocations using evidence-based methods. Methods and results from the 2011 Los Angeles Coordinated HIV/AIDS Needs Assessment–Care (LACHNA-Care) study are presented. Individual-level weights were applied to expand the sample from 400 to 18 912 persons, consistent with the 19 915 clients in the system. Awareness, need, and utilization for medical outpatient care were high (>90%). Other services (eg, child care) had limited awareness (21%). Majority of participants reported at least 1 service gap (81%). Lack of insurance (risk ratio [RR] = 3.0, 95% confidence interval [CI]: 1.5-6.2), substance use (RR = 2.9, 95% CI: 1.3-6.4), and past lapses in medical care (RR = 2.8, 95% CI: 1.3-5.9) were associated with gaps. Within clusters, past incarceration was associated with gaps for housing (RR = 13.5, 95% CI: 3.5-52.1), transportation (RR = 3.2, 95% CI: 1.2-8.4), and case management (RR = 4.0, 95% CI: 1.3-12.2). Applied methods resulted in representative data instrumental to RW program planning efforts.
The authors sought to determine the prevalence of unknown HIV status among emergency department (ED) patients, how it has changed over time, and whether it differs according to patient characteristics.
The authors used electronic medical record data to identify whether HIV status was known or unknown among patients aged ≥13 seen in the ED of a large, urban medical center between 2006 and 2011. The authors used multivariate logistic regression to identify the characteristics associated with unknown HIV status.
The prevalence of unknown HIV status decreased each year, from 87.7% in 2006 to 74.9% in 2011 (P < .001). Characteristics associated with unknown HIV status included being nonblack, in the youngest and oldest age-groups, and nonpublically insured. Compared to men, women without prior pregnancy were equally likely to have unknown HIV status, but women with prior pregnancy were significantly less likely to have unknown HIV status.
The prevalence of unknown HIV status is decreasing, but in 2011 75% of ED patients aged ≥13 still had unknown status, and it was associated with specific patient characteristics. Understanding the trends in the prevalence of unknown HIV status and how it is associated with patient characteristics should inform the design and implementation of expanded HIV-testing strategies.
Late presentation of patients contributes significantly to the high mortality reported in HIV -care and treatment programs in sub-Saharan Africa.
A cross-sectional study was conducted to assess factors associated with late engagement to HIV care at the Academic Model Providing Access to Healthcare in western Kenya. Late engagement was defined as baseline cells/mm3 ≤100/µL.
Of the 10 533 participants included in the analysis, 67% were female and mean age was 36.7 years. Overall, 23% of the participants presented late. Factors associated with late engagement included male gender (adjusted odds ratio [AOR]: 1.54, 95% confidence interval [CI]: 1.35-1.75), older age (AOR: 1.62, 95% CI: 1.02-2.56), and longer travel time to clinic (AOR: 1.18, 95% CI: 1.04-1.34).
Nearly one-quarter of HIV-infected patients in our setting present with advanced immune suppression at initial encounter. Being male, older age, and living further away from clinic are associated with late engagement to care.
The HIV/AIDS scenario all over the world is complicated by the stigmatic and discriminative attitudes toward the HIV-infected individuals.
In this facility-based, cross-sectional study, 104 HIV-positive patients were assessed regarding their personal experience with HIV-related stigma and discrimination using a Revised HIV Stigma Scale. The association between stigma and factors such as socioeconomic status and gender was tested using chi-square test, and P < .05 was considered statistically significant.
A large proportion (41.3%) of the participants were in the age-group of 26 to 35 years. Confidentiality of the HIV positivity status was maintained only in 14.4% of the participants. Compared to females (48.2%), more than half (51.5%) of the male participants had experienced HIV/AIDS-related personalized stigma (P > .05).
HIV-related stigma and discrimination are the major social determinants driving the epidemic, despite the advances in medical treatment and increases in the awareness about the disease.
The purpose of establishing integrated counseling and testing center (ICTC) is to detect HIV at the earliest time, providing information on modes of transmission and prevention of HIV by promoting behavioral change and reducing vulnerability, and informing individuals on HIV prevention, care, and treatment services.
To know the awareness of the clients about ICTC before pretest counseling.
This facility-based cross-sectional study was conducted among 105 pretest counseling clients who visited ICTC for the first time in 3 ICTCs of tertiary care hospitals attached to a medical college in Mangalore.
Majority of the clients were pregnant women (n = 57, 54.30%), and most of the clients were referred by the treating doctor (n = 91, 86.7%). Most of the clients, being unaware of ICTC, are not aware of its functions and activities.
Although ICTCs have been functional for nearly a decade, the awareness of ICTC and its functions among the people is poor.
Health care workers (HCWs) seek, treat, and care for patients living with HIV/AIDS on a daily basis and thus face a significant risk to work-related infections. To assess the knowledge, attitude, and practices regarding occupational HIV exposure and protection among HCWs in low HIV prevalence areas of rural China.
A cross-sectional questionnaire survey was carried out among all medical units in Pucheng County, Shaanxi, China.
Response rate of this study was 94%. The average overall knowledge score of HCWs was 10.9 of 21.0. Deficiencies in general, transmission, exposure, and protection knowledge were identified among HCWs at all levels. A high rate of occupational exposure (85%) and lack of universal precautions practice behavior were recorded. Significant predictors of universal precautions practice behavior were female sex, prior training, and greater knowledge about HIV/AIDS.
Health care workers at various levels have inadequate knowledge on HIV/AIDS and do not practice universal precautions. Nurses and medical technicians at the county level faced more occupation risk than other HCWs. The key of AIDS training for different levels of HCWs should be distinguished.
In 2006, the US Centers for Disease Control and Prevention recommended HIV testing for all adolescents and adults aged 13 to 64 in health care settings with a HIV prevalence of at least 0.1%. However, 55% of US adults have never been tested and therefore do not know their HIV status. To understand suboptimal HIV testing rates, this study sought to illuminate interpersonal and intrapersonal physician barriers to HIV testing. One hundred and eighty physicians from health centers in Houston completed a survey based on Cabana’s Knowledge, Attitudes and Behaviors model. One-third of the physicians faced at least 1 interpersonal barrier to HIV testing, such as a difference in age or language. Many (41%) physicians faced at least 1 intrapersonal barrier, such as believing their patients would be feeling uncomfortable discussing HIV. Notably, 71% of physicians would prefer their patients ask for the test. A patient-engaging campaign may be an innovative solution to increasing HIV testing and reducing the number of undiagnosed persons.
The study describes the HIV care providers’ sociodemographic and medical practice characteristics and the health care services offered to patients during medical care encounters in Houston/Harris County, Texas. We used data from the pilot cycle of the Centers for Disease Control and Prevention Medical Monitoring Project Provider Survey conducted in June to September 2009. The average age and HIV care experience of the providers were 46.7 and 11.7 years, respectively, and they provided care to an average of 113 patients monthly. The average proportion of HIV-infected patients seen per month by race/ethnicity was 43.3% for blacks, 28.5% for whites, 26.6% for Hispanics, 1.3% for Asians, and 0.6% for other races. A total of 67% of providers offered HIV testing to all patients 13 to 64 years of age. Most HIV care providers (73.9%) reported that patients in their practices sought HIV care only after experiencing symptoms. Understanding the HIV care delivery system from providers’ perspectives may help enhance support services, patients’ ongoing care and retention, leading to improved health outcomes.
HIV-associated neurocognitive disorder (HAND) is a great source of morbidity in sub-Saharan African region. However, the magnitude of this problem remains largely uninvestigated despite having the largest number of population with HIV/AIDS. The aim of this study is to determine the prevalence of HAND among patients attending a tertiary health facility in Nigeria.
We conducted a cross-sectional study among HIV-positive patients on antiretroviral therapy (ART) for at least 1 year. They were assessed using the International HIV Dementia Scale, Word Recall Test, Stick Design Test, Subjective Cognitive Complaint Questionnaire, Alcohol Use Disorder Identification Test, Drug Abuse Screening Test, Center for Epidemiological Study–Depression Scale, Instrumental Activity of Daily Living, and neurological examination. The CD4 count and viral load were determined for all the participants. A consensus diagnosis was made on each case based on the Frascati criteria. Data obtained were analyzed using "SPSS" for Windows version 15.
A total of 418 HIV-positive patients participated in the study, of which 325 (77.8%) are females. The mean age (standard deviation) of the participants was 37.2 (9.3) years. The prevalence of HAND was 21.5% (95% confidence interval [CI] = 17.6%-25.4%), of which 9.6% were asymptomatic. The significant predictors of HAND in this study are duration of illness (odds ratio [OR] = 1.33 P < .001), detectable viral load (OR = 0.19, P < .001), CD4 count (OR = 0.99, P < .001), education (OR = 0.94, P = .011), stopping medication (OR = 3.55 P = .01), and severity of illness (OR = 1.24, P = .005).
One-fifth of the HIV-positive patients in this study had HAND. Various sociodemographic and clinical features were related to the prevalence of HAND.
We sought to measure resident physician knowledge of HIV epidemiology and screening guidelines, attitudes toward testing, testing practices, and barriers and facilitators to routine testing.
Resident physicians in internal medicine, pediatrics, obstetrics and gynecology, and emergency medicine were surveyed.
Overall response rate was 63% (162 of 259). Half knew details of the HIV screening guidelines, but few follow these recommendations. Less than one-third reported always or usually performing routine testing. A significant proportion reported only sometimes or never screening patients with risk factors. This was despite a strong belief that HIV screening improves patient care and public health. The most common barriers to testing were competing priorities and forgetting to order the test. Elimination of written consent and electronic reminders was identified as facilitators to routine testing. Although an institutional policy assigns responsibility for test notification and linkage of HIV-positive patients to care to the HIV care program, only 29% were aware of this.
Few resident physicians routinely screen for HIV infection and some don’t test patients with risk factors. While competing priorities remain a significant barrier, elimination of written consent form and electronic reminders has facilitated testing. Increasing the awareness of policies regarding test notification and linkage to care may improve screening.
Overweight and obesity are increasingly prevalent among HIV-infected populations. We describe their prevalence and associated risk factors among HIV-infected adults in Dar es Salaam, Tanzania.
A cross-sectional study was conducted to determine the proportion of patients who were overweight or obese at enrollment to care and treatment centres from 2004 to 2011. Multivariate relative risk regression models were fit to identify risk factors.
A total of 53 825 patients were included in the analysis. In all, 16% of women and 8% of men were overweight, while 7% and 2% were obese, respectively. In multivariate analyses, older age, higher CD4 count, higher hemoglobin levels, female sex, and being married were associated with obesity and overweight. World Health Organization HIV disease stage, tuberculosis history, and previous antiretroviral therapy were inversely associated with obesity and overweight.
Overweight and obesity were highly prevalent among HIV-infected patients. Screening for overweight and obesity and focused interventions should be integrated into HIV care.
The aims of this study were to describe how people living with HIV (PLWH) perceive hope and illustrate implications for HIV care and treatment. This is a qualitative study done to explore perceptions and meanings of hope among PLWH attending care and treatment clinics in Dar es Salaam, Tanzania. In all, 10 focus group discussions and 9 in-depth interviews were conducted. People living with HIV described the following 3 dimensions of hope: cognitive, positive emotions, and normalization. Being cognizant of the effectiveness of antiretroviral treatment (ART) often led to positive emotions, such as feeling comforted or strengthened, which in turn was related to positive actions toward normalizing life. Improved treatment outcomes facilitated hope, while persistent health problems, such as ART side effects, were sources of negative emotions contributing to loss of hope among PLWH. Hope motivated positive health-seeking behaviors, including adherence to ART, and this may guide interventions to help PLWH cope and live positively with HIV.
This community-based cross-sectional epidemiological study was performed to assess the awareness and attitude of youths toward AIDS in a rural area of West Bengal in India.
Study population included 190 individuals (15–24 years). Data were collected using a semistructured, pretested questionnaire and analyzed using SPSS version 17 by logistic regression model.
It was revealed that older youths and particularly men compared to women had more comprehensive knowledge of AIDS than adolescents. Education, media exposure, marriage, and possessing above poverty level (APL) status, all had stronger positive association with youths (more in men) having comprehensive knowledge of AIDS. Older, never married youths, and particularly men were more likely than adolescents to have accepting attitudes toward people living with HIV/AIDS. Education, media exposure, and not having below poverty level card, all had stronger positive association with youths having accepting attitudes toward women than toward men. Surprisingly among the male APL population, this association was negative.
Educational and socioeconomic setbacks should be overcome in order to impose a better and justified attitude toward HIV/AIDS. Improved health conditions, proper counseling, and knowledge are essential to break the barriers of communication and ignorance toward HIV/AIDS in these parts of the developing countries.
Physicians’ ability to provide care to patients living with HIV/AIDS (PLWHA) in the Eastern Caribbean is influenced by economic constraints, sociocultural norms that govern interpersonal interactions, and the pervasive stigma linked to the disease. Although the economic environment determines national capacity to acquire various treatment and monitoring technologies, Eastern Caribbean physicians respond to practicing in a resource-limited setting by making choices that are influenced by the collectivist ethos that governs interpersonal relationships. Through qualitative interviews, the study finds that the social stigma associated with the disease requires physicians to "go the extra mile" to provide care in ways that allow PLWHA to protect their privacy in small, closely networked societies.
Knowledge of risk factors for HIV transmission in high-risk population plays a critical role in averting the risk of HIV transmission. In Pakistan, injection drug users (IDUs) constitute the core risk group of HIV prevalence, where the epidemic has transitioned to a "concentrated level." Still nothing is known about the role of knowledge in HIV transmission and HIV sero-conversion among IDUs in Pakistan.
From 2009 to 2011, a nested case–control study was conducted in a cohort of 636 IDUs receiving harm reduction services in the mega city of Karachi.
In multivariable regression analysis, 3 factors, namely HIV does not spread through unprotected sex (adjusted odds ratio [AOR]: 3.1, 95% confidence interval [CI] 1.39-6.90, P value .01), HIV does not transmit by sharing syringes (AOR: 3.5, 95% CI 1.97-6.40, P value <.00), and the risk of HIV cannot be minimized by using new syringe every time (AOR: 2.0, 95% CI 1.16-3.60, P value .01), were significantly associated with the incident cases of HIV.
The study findings suggest the association between knowledge of HIV transmission and HIV sero-incident cases.
There has been several reports of an MND like syndrome in HIV-1 infection, however the data is still sparse. Furthermore, HIV-associated amyotrophic lateral sclerosis (ALS) syndrome differs from the classical ALS in some key aspects.. A 44-year-old male presented with a history of insidious onset and gradually progressive asymmetric weakness of lower limbs. He also complained of thinning in both legs, the left leg more than the right since 1 year along with spontaneous twitching of muscles in both the thighs. On neurological examination, the assessment of higher mental functions was normal. There were no cranial nerve deficits. Motor power was grade 5/5 (Medical Research Council scale) in both the upper limbs and 4+ at hips and knees bilaterally, 5 at right ankle, and 4+ at left ankle. All the deep tendon reflexes were brisk with extensor planter responses. There were no cerebellar signs or sensory deficits. HIV-1 was reactive in enzyme-linked immunosorbent assay. Electrophysiological studies were conducted per the MND protocol.None of the nerves studied showed an abnormal drop in compound muscle action potential amplitude with proximal stimulation. There was evidence of diffuse spontaneous activity, which manifests as fibrillation and fasciculation potentials in most muscles tested . Overall there seems to be sufficient evidence toimplicate HIV as a potential cause of an ALS-like disorder, but one must also consider the possibility of coincidental HIV infection in patients who have sporadic ALS.
For the establishment and monitoring of the immune status, CD4 count is critical.
To determine the CD4 count range of apparently healthy Nigerians resident in Ilorin and compare with the national value.
An automated blood analyzer was used to determine the full blood count and CD4 count. The percentage of CD4 count was derived by using other variables.
Of the 1205 participants, the reference CD4 count (percentage of CD4) range for adult was 400 to 1288 cells/mm3 (19%-48%) and for children was 582 to 3652 cells/mm3 (17%-50%). CD4 count and percentage of CD4 were significantly (P = .001) higher in females than in males, and the CD4 count declined significantly with increasing age (r = –.174, P ≤ .0001). The percentage of CD4 count shows less variation with age (r = –.051, P = .076). Adult residents of Ilorin had significantly lower absolute mean CD4 count (808 ± 260) than that of the national reference values of 847.0 ± 307.0 cells/mm3 (P = .001).
We therefore advocate the use of CD4 count range derived in this study is lower than that of the national reference values.
Given the emerging data suggesting the key role of brain-derived neurotrophic factor (BDNF) in the immune system, we assessed longitudinally whether BDNF depletions induced by hazardous alcohol use (HAU) would impact a response to antiretroviral therapy (ART).
In a prospective single-site cohort, virological and immunological responses to ART in 200 hazardous and 200 nonhazardous users were obtained, along with plasma BDNF levels.
Hazardous drinkers were more likely to have BDNF levels <4000 pg/mL (odds ratio [OR] = 1.6, P = .01). Participants with BDNF <4000 pg/mL were less likely to have CD4 counts of more than 500 cells/mm3 (P = .02) and to achieve viral suppression over the follow-up period (OR = 1.5, P = .03). Multivariate analysis confirmed the significant role of HAU and low BDNF in predicting viroimmune responses.
Hazardous alcohol use was associated with BDNF alterations, which in turn were linked to a limited response to ART in terms of viral suppression and CD4 count improvements.
To asses morphological and morphometrical alterations of oral squamous epithelial cells in HIV infected individuals, and determine its diagnostic significance for HIV infection.
Informed Consent was obtained from all study subjects. 40 adult HIV infected patients (experimental group) and 40 adult non-infected volunteers (control group) participated. Age, occupation, and relevant medical history were recorded. The following laboratory tests reports were recorded: complete blood cell counts, blood glucose levels, serum iron and erythrocyte sedimentation rate. Oral smears were collected from normal appearing tongue and buccal mucosa of the individuals by exfoliative cytology. The cells were morphologically analysed and the nuclear area (NA), the cytoplasmic area (CA) and the nucleus-to-cytoplasm area ratio (NA/CA) were calculated. Cell yield, cell cohesion, presence/absence of inflammatory cells and candida were observed.
The cytological smears of HIV patients showed abundant cell yield and the epithelial cells were found to be in close cohesive clusters and both findings were found to be statistically significant. Nuclear cytoplasmic ratio was seen to be increased in 93.8% of HIV positive patientsand Mild to moderate pleomorphism was observed in 17.9% of HIV positive patients. HIV positive patients had a diminished inflammatory response and this was found to be statistically significant.
Statistically significant deviations from normal oral epithelium were found in the study conducted. With further research, oral exfoliative cytology may form a new, painless, inexpensive diagnostic method for HIV infections.
Cerebellar complications of HIV infection primarily manifested in ataxia, usually arise as the result of cerebellar lesions due to opportunistic infections, vasculitis or neoplastic processes. A 28 year old female known to have HIV infection for last four years, presented to our hospital with progressive unsteadiness in walking, slurring of speech and intention tremors for the last two months. There was no family history of similar complaints, and she was on Anti retroviral treatment for last one and a half years. The results of examination were notable for severe dysarthria, slow saccades, a conspicuous dysmetria and dysdiadokokinesia. She had no cognitive, sensory or motor deficits. MRI revealed diffuse cerebellar atrophy. Extensive laboratory work up failed to disclose a cause for subacute ataxia. Isolated cerebellar degeneration in an HIV patient is rare and should prompt a diagnostic work up.
An HIV transmission prevention program incorporating universal voluntary counseling and testing (UVCT) was conducted in a general practice (GP) clinic of a Thai hospital. Of the 494 participating patients, 356 (72%) accepted HIV-UVCT. Independent factors associated with HIV-UVCT acceptance included participating in the program after office hours (4-8
Children with HIV infection are often reported to be short. The aim of this study was to assess the prevalence of HIV-associated short stature in HIV endemic setting.
Data were obtained by retrospective review of the electronic medical records. Patients were grouped into various clinical categories. For each category, the proportion of patients with height-for-age Z score of less than –2 standard deviation [SD] and of less than –3 SD was determined.
The prevalence of short stature (less than –2 SD) was 28.4%. Severe short stature (less than –3 SD) is more likely with percentage of CD4 <15% (odds ratio [OR]: 3.30, confidence interval [CI]: 1.51-7.09, P = .002) and with males (OR: 1.49, CI: 1.19-1.87, P = .001). Severe short stature is more likely with viral load >400 copies/mL (OR 2.64, CI 1.27-5.38, P = .008) and poor adherence (<95%; OR 1.72, CI 1.03-2.05, P = .037).
In Botswana, short stature affects a quarter of HIV-infected children and severe short stature is associated with poor adherence to antiretroviral treatment, severe immunosuppression, and virologic failure.
The incidence of Kaposi sarcoma (KS) decreased dramatically after the introduction of highly active antiretroviral therapy (HAART). This study determined the ongoing incidence of and mortality from KS in HIV-infected adults from 1998–2012 in Fresno County, California. The role of virologic control and immune reconstitution was assessed.
Incident cases were identified from the state Electronic HIV/AIDS Reporting System (EHARS), the California Cancer Registry, and hospital records of the county HIV treatment center.
From 1998–2012, the average incidence of KS was 0.51 cases per 100,000 person-years. Of the 66 cases of KS there were 20 deaths, with 85% of the mortality occurring in the first 12 months. Among patients on HAART achieving HIV RNA <400 copies/uL, but with a <50 cell/uL increase in CD4 count there was no improvement in mortality.
The incidence of KS remains stable since 1998 with a 12-month mortality of 30%.
In 2006, the US Centers for Disease Control and Prevention recommended routine HIV testing in health care settings and called for HIV testing campaigns targeting African Americans. In a 2011 national survey, 63% of African Americans wanted information on HIV testing.
In our study, 176 African Americans were surveyed to determine channels and spokespersons for an HIV testing campaign.
Among 9 media channels, the top 3 ranked as "very likely" to convince them to get HIV tested were television, poster, and brochure. Among 10 spokespersons, the top 3 were doctor, nurse, and "real person like me."
The media are a cost-effective strategy to promote HIV prevention. Posters and brochures are inexpensive and easy to reproduce for clinical settings. Television campaigns may be feasible in clinics with closed-circuit televisions. Research is needed on campaign messages. An effective health center HIV testing campaign may help mitigate the disproportionate toll HIV is having on African Americans.
Patients living with HIV/AIDS face large societal and medical challenges. Inviting patients to read their doctors’ visit notes via secure electronic portals may empower patients and improve health. We investigated whether utilization and perceptions about access to doctors’ notes differed among doctors and patients in an HIV/AIDS clinic versus primary care setting. We analyzed pre- and 1-year postintervention data from 99 doctors and 3819 patients. HIV clinic patients did not report differences in perceived risks and benefits compared to primary care clinic patients, however, they were more likely to share notes with friends (33% versus 9%, P = .002), other health professionals (24% versus 8%, P = .03), or another doctor (38% versus 9%, P < .0001). HIV clinic doctors were less likely than primary care doctors to change the level of candor in visit notes (P < .04). Our findings suggest that HIV clinic patients and doctors are ready to share visit notes online.
To determine the optimal time to track patients, we evaluated the outcomes of patients traced after missing their return visits at 3 periods, 8, 30, or 90 days, at the Infectious Diseases Clinic in Kampala, Uganda. During the study period from January to December 2011, the proportion of untraceable patients was 2 (4%) after 8 days, 12 (10%) after 30 days, and 13 (15%) after 90 days. More than 75% of the patients who died had a CD4 count of <200 cells/mm3 at their last visit. In conclusion, tracking patients after 1 week of a missed return visit should be the preferred method of tracking. If resources are limited, patients with CD4 counts <200 cells/mm3 need to be targeted for tracking, as they are most at risk of dying if they interrupt treatment.
Few global studies have assessed HIV clinician–patient communication regarding cardiovascular disease (CVD) risks.
We conducted a multicountry, comparative, cross-sectional survey of HIV-infected individuals in 12 countries on 5 continents in 2010, with 100 to 200 enrollees per country. HIV-infected adults >17 years and on antiretroviral therapy were recruited in clinics and community organizations and surveyed via direct interview, telephone encounter, or online. Chi-square analyses were performed with an 80% power to detect a difference of >20%.
Of 2035 participants, 37% were women. Prevalence of self-reported CVD risk factors was 28% overall, and greater CVD risk was present in 55% of patients in North America, 12% in Africa, and 26% to 28% on other continents. Only 19% of patients ever discussed CVD with their physician, and 31% had ever discussed hypertension, hypercholesterolemia, family history of CVD, or smoking; these findings were true for HIV clinicians in all regions of the world. Forty-four percent of smokers reported never discussing smoking with their HIV clinician.
We found that HIV clinicians worldwide are not sufficiently addressing CVD risk factors with their patients. Expanded training and education for HIV clinicians should include effective approaches to the mitigation of CV risk factors.
Bacillary angiomatosis (BA) is a rare manifestation of infection caused by Bartonella species, which leads to vasoproliferative lesions of skin and other organs. Bacillary angiomatosis affects individuals with advanced HIV disease or other immunocompromised individuals. In sub-Saharan Africa, despite the high prevalence of HIV infection and documentation of the causative Bartonella species in humans, mammalian hosts, and arthropod vectors, BA has only rarely been described.
Three adult patients from Uganda and Kenya with deep purple dome-shaped papules or nodules of the skin underwent punch biopsies for histopathologic diagnosis. The biopsies of all 3 patients were sent to a local pathologist as well as to a dermatopathologist at the University of California, San Francisco.
All 3 patients were clinically suspected to have Kaposi sarcoma (KS), and local pathologists had interpreted the lesions as KS in 2 of the cases and nonspecific inflammation in the third. Histologic examination by dermatopathologists in the United States revealed nodular dermal proliferations of irregular capillaries lined by spindled to epithelioid endothelial cells. The surrounding stroma contained a mixed inflammatory infiltrate with lymphocytes, eosinophils, and neutrophils. Extracellular deposits of pale amphophilic granular material were noted in the surrounding stroma. A Warthin-Starry stain highlighted clumps of bacilli, confirming the diagnosis of BA.
These 3 cases, to our knowledge, are the first reports of BA in East Africa in the biomedical literature. Each had been originally incorrectly diagnosed as KS. We speculate BA is underdiagnosed and underreported in resource-poor regions, such as sub-Saharan Africa, that have high endemic rates of HIV infection.
There is limited information on efficacy and durability of second-line antiretroviral therapy (2NL) beyond 12 months in resource-limited settings. A total of 73 patients were enrolled into a prospective 2NL observational cohort in Nigeria. Second-line antiretroviral therapy consisted of lopinavir/ritonavir plus nucleoside reverse transcriptase inhibitors. Time on 2NL ranged from 15 to 31 months. Genotypes were retrospectively done and not available to guide second-line regimen choice. At enrollment, median CD4 count was 121 cells/mm3, and median time on first-line antiretroviral therapy (1SL) was 24 months. At 6 to 9 months on 2NL, 72.6% (intention to treat [ITT]) and 88.3% (on treatment [OT]) had an undetectable viral load (UDVL). At 12 months, 65.8% (ITT) and 90.57% (OT) had UDVL. At >12 to 24 months and at >24 months, 57.5% (ITT) and 91.3% (OT) had UDVL. No statistically significant association was observed between CD4 at 2NL start, sex, genotypic sensitivity score of 2NL, or tenofovir (TDF) use in 1SL and viral suppression. Two patients developed major protease inhibitor mutations while on 2NL. We observed a high degree of viral suppression at 12 months and little loss of viral suppression thereafter.
To determine the rate of and predicting factors for virologic failure among HIV-infected patients with persistent low-level viremia (PLV) under antiretroviral therapy (ART), a retrospective cohort study was conducted among HIV-infected patients who experienced PLV under ART. Persistent low-level viremia was defined as HIV RNA level at 50 to 1000 copies/mL for at least 2 consecutive visits. Of 68 patients, mean ± standard deviation age was 35.2 ± 9.0 years and 64.7% were males. Median (interquartile range [IQR]) CD4 count was 94 (26-264) cells/mm3 and baseline HIV RNA was 112 000 (1 090-461 500) copies/mL. During the median (IQR) follow-up period of 5.7 (3.4-10.3) years of ART, the rate of virologic failure was 38.2%. In multivariate analyses, only maximum amplitude of HIV RNA >400 copies/mL during PLV (hazard ratio = 5.668; 95% confidence interval, 1.888-17.014; P = .002) significantly predicted virologic failure. Patients with PLV >400 copies/mL are more likely to develop virologic failure and should be closely monitored. Interventional studies to prevent virologic failure in these patients are needed.
The Centers for Disease Control and Prevention have recommended routinely testing patients (aged 13-64) for HIV since 2006. However, many physicians do not routinely test. From January 2011 to March 2012, we conducted 18 in-depth individual interviews and explored primary care physicians' perceptions of barriers and facilitators to implementing routine HIV testing in North Carolina. Physicians' comments were categorized thematically and fell into 5 groups: policy, community, practice, physician, and patient. Lack of universal reimbursement was identified as the major policy barrier. Participants believed endorsement from the United States Preventive Services Tasks Force would facilitate adoption of routine HIV testing policies. Physicians reported HIV/AIDS stigma, socially conservative communities, lack of confidentiality, and rural geography as community barriers. Physicians believed public HIV testing campaigns would legitimize testing and decrease stigma in communities. Physicians cited time constraints and competing clinical priorities as physician barriers that could be overcome by delegating testing to nursing staff. HIV test refusal, low HIV risk perception, and stigma emerged as patient barriers. Physicians recommended adoption of routine HIV testing for all patients to facilitate and destigmatize testing. Physicians continue to experience a variety of barriers when implementing routine HIV testing in primary care settings. Our findings support multilevel approaches to enhance physician routine HIV testing in primary care settings.
Assessment of longitudinal adherence patterns on virologic and immunologic responses to HAART in perinatally acquired HIV patients has not been studied.
Perinatally infected pediatric HIV patients with adherence documented at least twice and corresponding viral load and T-cell (%) data measured during 2008-2009 were studied. Multiple adherence measures were utilized to identify patients with persistent adherence, nonadherence, or alteration of adherence. Virologic and immunologic outcomes were assessed.
Persistent adherence, nonadherence, and alteration of adherence to HAART were recorded in 41.9%, 8.1%, and 50.0% of 62 studied patients. Persistent adherence was associated with higher likelihood for persistent virologic suppression and lower risk for persistent virologic failure.
Alteration of adherence to HAART is a significant predictor of persistent virologic failure and high viremia in perinatally infected HIV patients. Implementation of longitudinal adherence assessments may target patients with nonsustained adherence patterns and help decrease the risk for virologic failure and disease progression.
Effective follow-up of mother–infant pairs is critical for ensuring the success of preventing mother-to-child transmission (PMTCT) programs. The objective of this study was to identify factors associated with health outcomes of exposed infants in a PMTCT program in the Democratic Republic of Congo (DRC). Data were collected from January 2005 through December 2008 in 2 maternities in Kinshasa, DRC. The exposed infant’s health status was used as outcome. Multiple logistic regressions were used to identify the determinants of infant outcomes. A total of 309 mother–infant pairs were included in this study. Younger maternal age, breast-feeding but weaning before the age of 6 months, and HIV testing of the child and a mother who is not sick were associated with better infant health outcome. The follow-up of mother–infant pairs in PMTCT programs remains critical and challenging. There is a need for innovative and efficient strategies to improve retention of mother–infant pairs in PMTCT programs.
This cross-sectional study approached emergency department (ED) patients after the treating physician’s disposition decision to measure patient understanding of whether or not they had received an HIV test during their ED encounter. Of the 300 respondents, 24 were excluded due to missing data or because they had received an ED HIV test. Mean age was 41 years, 51% were men, 61% were black, and 29% had no high school degree. There were 5.8% (95% confidence interval: 3.5%-9.4%) who erroneously reported HIV test delivery during their ED course. Our results suggest a small but significant minority of patients falsely assume that they have been tested for HIV during their ED visit. This misperception could have broad implications, leading to less frequent subsequent testing, false reassurance of HIV-negative status, and inaccuracies in surveillance estimates or surveys that depend on self-report.
Patients with HIV are at increased risk of malignancy, particularly lymphoma, which is the most common malignancy leading to death. With the advent of highly active antiretroviral therapy (HAART), patients live longer but have a longer duration of antigenic stimulation, increasing the prevalence of AIDS-related lymphoma (ARL) in the population living with HIV. Highly active antiretroviral therapy plays a direct role in preserving the immune system, helping to decrease the incidence of ARL. We present a case of a female patient with HIV (CD4 count of 576 cells/mm3) diagnosed with a stage III-B non-Hodgkin lymphoma in 2009 while off HAART. She was subsequently started on HAART, leading to full resolution of her lymphoma without any chemotherapeutic intervention. She was last seen in the clinic in December 2013 without any evidence of recurrence of her lymphoma. To our knowledge, this is the first case report of a stage III-B non-Hodgkin lymphoma in an HIV-infected patient, which resolved with only HAART.
This report describes the HIV-related health care practices and associated support service needs of a sample of HIV-positive incarcerated men in Puerto Rico.
Data are derived from a random sample of HIV-positive incarcerated men (n = 37) in Puerto Rico who completed a brief survey. Analysis included descriptive statistics to examine lifetime prevalence of substance use, selected health care practices, receipt of services, and hepatitis C virus (HCV) infection.
Most men (97.3%) reported history of alcohol or drug use, prior incarceration, and drug use as the main risk factors for HIV infection (73.0%). In all, 83.8% of the men reported having had their first HIV screening test in a correctional facility, 55.6% reported intermittent HIV therapy, and most (83.8%) had also been diagnosed with HCV.
Correctional facilities can be important settings for engaging high-risk populations in health care, capturing and enrolling unidentified HIV/HCV infections for clinical care, and engaging in substance abuse treatment. In order for these public health outcomes to be achieved, it is important to consider strategies to optimize care inside prison and in the community.
Behavioral interventions have utilized a variety of strategies and components to reduce HIV risk. This article describes the partner intervention, a couple-based group HIV risk reduction intervention implemented in 6 urban community health clinics in Lusaka, Zambia, and examines the components of the intervention and their relationship with condom use. Couple members completed assessments on condom use, acceptability, willingness to use condoms, communication, intimate partner violence (IPV), self-efficacy, and HIV information at baseline and 6 months’ follow-up. This study examined the relative impact of elements of the intervention as predictors of condom use. Changes in acceptability had the greatest overall influence on condom use, followed by social support, relationship consensus, and willingness to use condoms. Changes in self-efficacy, IPV, negotiation, and information had no influence. Results support the use of multidimensional approaches in behavioral interventions and highlight the importance of identifying critical elements of interventions to maximize risk reduction outcomes.
Rhodococcus equi, previously called Corynebacterium equi, is known to cause pneumonia in foals and swine. Although it was known to cause infection rarely in humans, R equi infection in humans has increased with the advent of HIV and increased use of immunosuppressants.
We report a case of a 48-year-old male patient with newly diagnosed HIV/AIDS presenting with recurrent R equi bacteremia, pericardial effusion, and pericardial cyst. The infection was treated with drainage of the pericardial effusion and cyst and 2 weeks of intravenous vancomycin and 6 months of oral azithromycin and levofloxacin.
Rhodococcus equi causes pericarditis and pericardial effusion. It can be effectively treated with debridement, drainage, and a prolonged course of antibiotics. In vitro antibiotic susceptibility should be checked as resistance to antibiotics can develop, especially if drainage is inadequate.
Despite treatment with potent and effective combination antiretroviral medications, the incidence of non-Hodgkin lymphoma (NHL) in the population living with HIV/AIDS remains significantly higher than that in noninfected individuals. The majority of the HIV-infected patients with NHL present with advanced stage extranodal disease of the B-cell phenotype. Lymphomas are the second most common tumors involving the heart in HIV-infected patients. Although the heart may serve as the primary focus of the lymphoma, in most HIV-related cases, cardiac lymphomatous involvement is part of a metastatic process that originated elsewhere.
Research has demonstrated that adherence to antiretroviral therapy (ART) results in lower rates of morbidity and mortality associated with HIV infection, yet adherence remains a challenge in resource-limited settings like the Dominican Republic. Clínica de Familia La Romana addressed this problem with an education-based adherence program for adult patients new to ART, and this retrospective cohort study aimed to evaluate the impact of this intervention. Appointment adherence and biological markers were assessed in cases and controls through 12 months. A total of 101 participants were included, with 61 controls and 40 cases. The baseline CD4 count was 162 and 157 cells/mm3 in controls and cases, respectively. Cases showed a 15-fold increase in CD4 count compared with a 2.5-fold increase in controls. Cases were more likely to adhere to appointments with adherence rates of 86% versus 76% in controls. There was no difference between the rates of treatment abandonment, transfer of care, or death.
Despite the 2006 US Centers for Disease Control and Prevention (CDC) recommendations for routine HIV testing in health care settings, many persons remain untested.
To determine physician barriers to HIV testing, we surveyed primary care physicians in community health centers in a high HIV prevalence city.
Primary care physicians were invited via e-mail to participate in a Web-based survey. One hundred and thirty-seven physicians participated (response rate: 43.9%).
Fifty-five physicians (41.0%) were unaware of updated CDC HIV-testing recommendations. Physicians were unaware that testing should be routinely offered in primary care settings caring for adolescents (62 physicians, 45.6%) and primary care settings caring for adults (33, 24.3%). Physicians were also unaware that teenage years patients aged 13 to 17 years (68, 49.6%) and adult patients aged 18 to 64 years (40, 29.2%) should be routinely HIV tested.
With the new 2013 US Preventive Services Task Force recommendations to support routine HIV testing, it is critical to address ongoing physician HIV-testing barriers to mitigate the HIV epidemic.
In this discourse analytic article, I discuss the shifting challenges of HIV/AIDS caregiving, as highlighted in previous research, as well as the similarities between past and present challenges as illustrated by the discourses of HIV/AIDS caregivers at a nonprofit organization in South Africa. Using data from interviews with staff members and volunteers, I illustrate how both past and contemporary challenges in HIV/AIDS caregiving relate to an inability to exercise control. Participants’ discourses revealed a contrast whereby, on one hand, they conveyed a sense of being in control over HIV, while, contradictorily, their accounts contained instances of lack or loss of control. I discuss the implications of barriers to control in HIV/AIDS caregiving and the role of communication and interaction research. I conclude by endorsing ongoing, regular assessments of the needs of those undertaking such work in order to identify their evolving needs in light of evolving challenges.
Eligibility criteria were (1) having previously failed first-line nonnucleoside reverse transcriptase inhibitor–based regimens and (2) having achieved virologic suppression >6 months while receiving a protease inhibitor (PI)-based regimen as second-line treatment. Eligible participants were randomized to receive either (1) ritonavir-boosted lopinavir (LPV/r) monotherapy (n = 29) or (2) LPV/r with optimized background regimens (OBRs; n = 31). Median duration of viral suppression before randomization was 45 months. At week 48, viral suppression during LPV/r monotherapy was 86.2% and did not differ from the suppression achieved with LPV/r with OBRs (87.1%, P = 1.000). However, persistent viremia during LPV/r monotherapy tended to be higher than during LPV/r with OBRs (10.3% versus 3.2%, P = .346). History of viral blip during virologic suppression with second-line PI-based regimen is a predictor of achieving viral suppression at all visits (adjusted relative risk 0.255 [95% confidence interval 0.080-0.821], P = .022). Use of LPV/r monotherapy as maintenance regimen in this study produced persistent viremia that tended to be higher than LPV/r monotherapy with OBRs.
This discursive article introduces HIV treatment as prevention (TasP) and identifies various models for its extrapolation to wider population levels. Drawing on HIV surveillance data for Jamaica and Barbados, the article identifies significant gaps in HIV response programming in relation to testing, antiretroviral treatment coverage, and treatment adherence, thereby highlighting the disparity between assumptions and prerequisites for TasP success. These gaps are attributable, in large part, to sociocultural impediments and structural barriers, severe resource constraints, declining political will, and the redefinition of HIV as a manageable, chronic health issue. Antiretroviral treatment and TasP can realize success only within a combination prevention frame that addresses structural factors, including stigma and discrimination, gender inequality and gender-based violence, social inequality, and poverty. The remedicalization of the response compromises outcomes and undermines the continued potential of HIV programming as an entry point for the promotion of sexual, health, and human rights.
Distal symmetrical peripheral neuropathy (DSPN) and sleep disturbances are among the most common complications reported in people living with the human immunodeficiency virus infection and acquired immunodeficiency syndrome (PLWHA). DSPN-pain is predominantly managed by using systemic agents with little evidence supporting their analgesic efficacy. The purpose of this study is to evaluate the effect of nighttime lower extremity splinting application on DSPN-related pain and sleep disturbances compared to a parallel splint liner application in PLWHA.
Forty-six PLWHA and DSPN were randomized to nighttime wearing of bilateral lower extremity splints or the liners only. Pain and sleep outcomes were measured at baseline, week 3, and week 6. The pain was measured using the Neuropathic Pain Scale and sleep using the Pittsburgh Sleep Quality Index.
Pain and sleep scores improved in both groups over time. The median percentage pain reduction at week 6 was 8% in the liner group and 34% in the splint group. The change in pain scores in the splint group was found to be significant over time, P < .0005. The contrast between the splint and liner groups was underpowered (26%) and was not found to be significant, P > .05. Sleep scores improved 20% from baseline to the end of the study in both groups; all participants were classified as poor sleepers.
The 6-week use of nighttime splints reduces DSPN-pain possibly by providing peripheral inhibition of external stimuli. Future studies are needed to validate this inhibitory intervention to manage DSPN in PLWHA and other neuropathic conditions.
We describe the rate of death and identify the determinants of survival in a cohort of adults starting antiretroviral therapy (ART) in 2 hospitals in Upper West Region, Ghana. Kaplan-Meier model was used to estimate the survival probability after ART initiation and Cox proportional hazard model used to assess the relationship between baseline variables and mortality. A total of 91 clients who were initiated on ART in both hospitals participated in the study. Clients staged in the World Health Organization (WHO) clinical stage III/IV had a higher risk of mortality than those staging I/II (hazard ratio [HR] of 3.93). Hemoglobin value at baseline with a cutoff ≥12 g/dL for women (and ≥13 for men) was strongly associated with mortality in participants with an HR of 3.87 (95% confidence interval [CI]: 0.71-21.19) for severe anemia, 2.11 (95% CI: 0.45-9.93) for moderate anemia, and 0.88 (95% CI: 0.16-4.82) for mild anemia. Anemia and WHO staging were independent predictors of mortality.
Cost-effective HIV prevention programs should target persons at high risk of HIV acquisition. We conducted an observational HIV incidence cohort study in Kisumu, Kenya, where HIV prevalence is triple that of the national rate. We used referral and venue-sampling approaches to enroll HIV-negative persons for a 12-month observational cohort, August 2010 to September 2011, collected data using computer-assisted interviews, and performed HIV testing quarterly. Among 1292 eligible persons, 648 (50%) were excluded for HIV positivity and other reasons. Of the 644 enrollees, 52% were women who were significantly older than men (P < .01). In all, 7 persons seroconverted (incidence rate [IR] per 100 person-years = 1.11; 95% confidence interval [CI] 0.45-2.30), 6 were women; 5 (IR = 3.14; 95% CI 1.02-7.34) of whom were ≤25 years. Most new infections occurred in young women, an observation consistent with other findings in sub-Saharan Africa that women aged ≤25 years are an important population for HIV intervention trials in Africa.
As countries consider a wider use of triple antiretroviral therapy (ART) in pregnancy, which in recent World Health Organization guidelines is called Option B+, this study sought to explore the potential implications of adopting Option B+ by characterizing HIV infection in pregnant women attending 2 semiurban antenatal clinics in Cameroon. In a descriptive cross-sectional study, consenting women were screened for HIV; positive samples were confirmed using an enzyme-linked immunosorbent assay test, and CD4 levels and HIV viral loads were determined using flow cytometry and reverse transcription–polymerase chain reaction, respectively. The seroprevalence of HIV in the 407 pregnant women screened was 8.4% (95% confidence interval: 5.9%-11.5%). The majority (82.4%) of HIV-positive women had CD4 counts >350 cells/mm3. A quarter (25%) had undetectable viral levels (<80 copies/mL). Adopting Option B+ in this setting would result in a 5-fold increase in the number of HIV-infected pregnant women being placed on lifelong triple ART.
HIV-infected individuals are at a high risk of developing arterial and venous thromboembolism. Opportunistic infections, protease inhibitors, low CD4 count, antiphospholipid antibodies, protein S, and protein C deficiencies are some important risk factors associated with it. However, thromboembolic phenomenon due to protein C deficiency has been rarely reported. We report a case of a 12-year-old girl with facial palsy due to middle cerebral artery infarct because of HIV infection and associated protein C deficiency.
Voluntary medical male circumcision (VMMC) is being suggested as an essential HIV prevention strategy in high-prevalence areas. These analyses reflect data collected from 360 married couples, 50% of which included a circumcised husband and the other 50% uncircumcised, in rural Malawi. Regardless of their circumcision status, men were more likely to perceive that being circumcised was less painful than having a tooth pulled, giving birth, and having malaria. Men reported having the same sexual pleasure regardless of the circumcision status, while women were 2.0 times more likely to report greater sexual pleasure with a circumcised partner. Participants identified the medical benefits of VMMC and highlighted the potential personal benefits of VMMC. As VMMC has become a promising method of HIV prevention, this study revealed opportunities for intervention development to increase rates of VMMC among men.
To study the AIDS welfare homes (AWHs) in Andalusia, assess their resources and the services provided, and describe the characteristics of their residents.
Cross-sectional, observational study; an interview questionnaire technique was used with the managers and the residents of the AWHs.
A total of 7 AWHs and 96 residents were included; 32% of the staff were health care workers and 45.5% volunteers. The occupancy rate was 86% (2007) and 96% (2008). Residents’ characteristics: mean age 45.6 years, 73% male, 92% with at least 1 AIDS-defining disease, median Karnofsky index 60 (50-80), and median Barthel index 80 (40-100). Half the residents had physical sequelae and 31% mental sequelae.
The AWHs perform an important role in the care of certain types of patients with HIV infection. They require human and material resources to be able to tackle the immense difficulties associated with this group of patients.
The risk for occupational exposure to HIV is a serious public health problem that is well characterized in the developed world, but less so in the developing countries such as Ghana. This study was undertaken to examine the characteristics of occupational exposure to HIV and the utilization of a risk assessment system (RAS)–based postexposure prophylaxis (PEP) among health care workers (HCWs) and health care students (HCSs) in the Korle-Bu Teaching Hospital (KBTH). During the study period (January 2005–December 2010), a total of 260 and 35 exposures were reported by HCWs and HCSs, respectively. Ward attendants reported the highest incidence rate of 6.46 of 100 person-years (P-Y). The incidence of high-risk exposures was 0.33 of 100 P-Y (n = 65); 60.0% occurred during a procedure of disposing of a needle and 24.6% during a cannula insertion. A total of 289 of the 295 individuals were administered PEP, of which 181 (62.6%) completed the 6-month follow-up testing schedule and none sero-converted. This shows that with a good RAS in place, it is possible to deploy an effective PEP program in a typical African teaching hospital like the KBTH in Accra, Ghana.
Sexually transmitted infections (STIs) significantly increase HIV transmission. Sexually transmitted infections may be asymptomatic and therefore remain undiagnosed in HIV-positive persons. Routine screening and treatment of STIs in HIV-positive high-risk populations in sub-Saharan Africa have not been described previously.
We reviewed data from an HIV-positive high-risk population at the Infectious Diseases Institute, Makerere University, a large urban HIV clinic, between July 2011 and April 2012. Our high-risk population cohort included female sex workers, long-distance drivers, barmaids, taxi drivers, commercial motorcycle "boda-boda" riders, soldiers, police officers, prison officers, security guards, prisoners, and fishermen.
Of 355 participants enrolled in the high-risk population’s program, 21.4% were diagnosed with an STI either clinically or microbiologically. The STIs diagnosed in this population were syphilis, hepatitis B, genital herpes, human papilloma virus infection (condylomata acuminata), nongonococcal urethritis (NGU), and gonorrhea. Rates of syphilis, hepatitis B, genital herpes, condylomata acuminata, NGU, and gonorrhea were 8.5%, 7.0%, 5.4%, 1.4%, 1.4%, and 0.3%, respectively.
Clinical and microbiologically diagnosed STIs were diagnosed in nearly one-fourth of the HIV-positive high-risk population. HIV care programs should note our high rates of STIs among HIV-positive high-risk populations and consider routine screening and treatment algorithms for these populations in their own settings.
Studies have identified several programmatic and nonprogrammatic indicators that affect adherence to highly active antiretroviral therapy (HAART). Depression has been shown to impact adherence to HAART. This cross-sectional analysis of data collected from Nigeria, Uganda, Zambia, and Tanzania in 2008 examined the relationship between levels of depressive symptoms, clinical progression, and adherence to HAART.
A multinational, multicenter, observational, retrospective cross-sectional evaluation of a population of focus comprised randomly selected patients on HAART. The dependent variable was adherence to HAART. The primary variable of interest to be assessed was patients’ level of depressive symptom score. A multivariable logistic regression model was used to examine the relationship between explanatory variables and adherence to HAART.
A total of 2344 patients were recruited for adherence survey. About 70% of the study sample reported having some level of depression. Logistic regression results show that patients who reported, respectively, low, moderate, and high levels of depressive symptoms are 35% (P < .001), 56% (P < .001), and 64% (P < .001) less likely to adhere to HAART than those who reported having no depressive symptoms. At multivariate analysis, adherence to HAART was independently associated with the levels of depressive symptoms, older age, CD4 count >200 cells/mm3, Truvada (tenofovir [TDF]/emtricitabine [FTC])-based regimens, good knowledge about HAART, and longer period on therapy.
These results indicate that mental health and clinical parameters are significant factors in determining patients’ adherence to their HAART, which need to be more aggressively addressed as a critical component of care and treatment support.
In Africa, HIV infection is considered a family disease. A retrospective cohort analysis was performed to describe the characteristics and outcome in 35 parent–child pairs taking antiretroviral therapy (ART) in separate adult and pediatric HIV clinics. In 26 pairs, ART was first initiated in children. Baseline median CD4 count was 122/mm3 in adults and 376/mm3 in children. World Health Organization stage 3 or 4 disease affected 49% of adults and 83% of children. In all, 3 parents and 1 child died. Hospitalization, poor adherence, missed appointments, or regimen change affected >50% of pairs on ART. Following tuberculosis diagnosis in their parents, 2 of the 5 children were not investigated. By week 104, 29 (83%) pairs remained on ART, and 69% of patients on ART were virologically suppressed. Parent–child pairs with advanced HIV infection had good outcomes when cared for in separate clinics. Establishing lines of communication between clinics is important. Family-centered services may provide more integrated care.
Little is known about the differences in clinical manifestations between women with various HIV-1 subtypes during acute (AI) and early (EI) HIV infection. In a longitudinal cohort study, clinical signs and symptoms among Uganda and Zimbabwe women with AI and EI were compared with HIV-negative controls; symptoms were assessed quarterly for 15 to 24 months. Early HIV infection was defined as the first visit during which a woman tested HIV antibody positive. Women who were HIV negative serologically but DNA polymerase chain reaction positive were considered AI. In all, 26 women were classified AI and 192 EI, with 654 HIV-negative controls. Primary HIV infection (AI and EI) was associated with unexplained fever (P <.01), weight loss (P <.01), fatigue (P <.01), inguinal adenopathy (P <.01), and cervical friability (P =.01). More women with subtype C infection had unexplained fever, fatigue, and abnormal vaginal discharge compared to subtype A or D infection. Inguinal adenopathy occurred less often in women with subtype A infection than those with subtype C or D infection.
We assembled a prospective cohort of 3144 children less than 15 years of age initiating antiretroviral therapy (ART) in Dar es Salaam, Tanzania.
The relationships of nutritional status and other baseline characteristics in relation to mortality were examined using Cox proportional hazards model.
Compared with children with weight for age (WAZ) > -1, those with WAZ ≤ -2 to < -3 had a nearly double risk of death (relative risk [RR], 1.85; 95% confidence interval [CI], 1.10-3.11), and among those with WAZ ≤ -3, the risk more than tripled (RR, 3.36; 95% CI, 2.12-5.32). Other baseline risk factors for overall mortality included severe anemia (P < .001), severe immune suppression (P = .02), history of tuberculosis (P = .01), opportunistic infections (P < .001), living in the poorest district (P < .001), and advanced World Health Organization stage (P = .003).
To sustain the obtained benefit of ART in this setting, interventions to improve nutritional status may be used as an adjunct to ART.
Absolute neutrophil counts (ANCs) are lower in East African adults. To assess the impact of lower ANCs, we reviewed data from HIV-infected Kenyan women receiving antiretroviral therapy antepartum and postpartum.
The Kisumu Breastfeeding Study (KiBS) participants received an antiretroviral regimen from 34 weeks’ gestation through 6 months postpartum. Measured ANCs and subsequent illnesses were reviewed. Adverse events (AEs) potentially attributable to neutropenia were identified, and ANCs were graded using the 2004 Division of AIDS table for Grading the Severity of AEs.
Among 478 women with
More than half of KiBS women met criteria for neutropenia. The mild clinical experience of most participants with low ANCs supports that these values might be typical for this population and may not result in adverse clinical sequelae.
The purpose of this case–control study was to identify risk factors for loss to follow-up (LTFU).
Cases and controls were selected from HIV-positive patients, aged 18 years and older, on antiretroviral therapy (ART) at the Infectious Diseases Clinic (IDC) in January 2008. As cases, we selected 209 patients who in 2008 did not return to the clinic within 90 days of their scheduled appointment date. As controls, we randomly selected 626 patients from the 5872 patients who were following up at the end of December 2008.
In multivariable logistic regression analysis, urban or semiurban residence, World Health Organization disease stage III or IV at ART initiation, a median CD4 count at last visit <200 cells/mm3, tuberculosis (TB) in the 6 months before the last visit, absence of counseling before ART initiation, and no disclosure of HIV status were associated with LTFU.
This study demonstrates the importance of close patient monitoring in advanced stages of disease, supportive counseling for patients initiating ART, extra psychosocial support for patients with TB and HIV coinfection, assisting patients with disclosure, and setting up a good referral system to retain patients on ART.
This study describes the epidemiologic features and clinical course of children with blood transfusion-associated HIV infection (TAHI) in Ibadan, Nigeria.
All children diagnosed to have TAHI at the University College Hospital, Ibadan, were studied and compared with children who acquired HIV vertically using the pediatric HIV database in the hospital.
Transfusion-associated HIV infection accounted for 14 (2.3%) of the 597 children diagnosed to have HIV infection between January 2004 and December 2011. The mean age at diagnosis of TAHI was 10.2 years and that of vertically acquired HIV infection was 3.9 years (P < .001). In 9 cases, blood transfusion took place in private hospitals and in 5 cases in public hospitals. Median interval between infection and diagnosis of AIDS was 84 months in cases with TAHI and 48 months in vertically acquired cases (P = .542).
Optimal blood safety practices are advocated for prevention of TAHI in Nigeria.
Nigeria has the world’s highest burden of pediatric HIV. In the face of paucity of monitoring tests in Nigeria, we studied the spectrum of pediatric mucocutaneous manifestations and evaluated their clinical utility as surrogate markers for immunodeficiency and plasma viral load levels.
Cross-sectional study comparing mucocutaneous manifestations in 155 HIV-positive children aged 12 weeks to 14 years with 155 HIV-negative children. Relationships between mucocutaneous manifestations in HIV-infected patients and their immunologic and virologic indices were analyzed.
Mucocutaneous lesions were seen in 53.5% of HIV-infected children compared with 18.1% of the controls. Prevalence of lesions increased with worsening levels of immunodeficiency and increasing viral loads (P < .01). Oral candidiasis, angular stomatitis, and fluffy hair were associated with more severe degrees of immunodeficiency.
Mucocutaneous disorders are common in HIV-infected children. Oral candidiasis and nutritional dermatoses can be used as surrogates for advanced or severe immunodeficiency.
In India, a zidovudine-based regimen is preferred as the first-line drug treatment for HIV, despite high rates of drug toxicity. This study estimates the treatment costs for HIV.
Eligible patients were enrolled from Antiretroviral Therapy Center, Christian Medical College, India. Baseline demographic and clinical characteristics, medical and nonmedical expenditure, and lost income were collected.
Of 41 patients enrolled and followed for 6 months, HIV treatment toxicity and opportunistic infections were reported by 12 (29%) and 13 (31.7%) patients, respectively. The median total costs, direct costs, and out-of-pocket expenditure were Indian rupees (INR) 9418 (US$181), 8727 (US$168), and 7157 (US$138), respectively. Diagnostic tests accounted for 58% of the expenses. HIV treatment accounted for 34% of the median income earned INR 21 000 (US$404). Expenditure for treatment with toxicity was 44% higher than without toxicity.
Current treatment is associated with toxicity, increasing treatment costs and imposing a significant economic burden.
Cryptococcal meningitis (CM) remains a significant HIV-associated opportunistic infection in Southeast Asia and Africa, with a high burden of disease and a high mortality rate despite the availability of antiretroviral therapy (ART). We retrospectively examined the utility of cryptococcal antigen screening to identify risk for CM among 211 Thai women initiating ART. Antigenemia prevalence was 11% (n = 9) among 84 women with a CD4 count <100 cells/mm3. Screening identified all women who later developed CM. Cryptococcal antigen titers decreased over time with ART. Our study confirmed findings from previous studies in Thailand and South Africa and provided novel observational data regarding the course of cryptococcal antigenemia in patients initiating ART and the poor efficacy of low-dose fluconazole prophylaxis in preventing CM among patients with antigenemia.
Access to parks improves overall health outcomes in the general population. Given that HIV infection has become a chronic disease to manage, among populations engaged in medical care, parks may be promoted as physical activity opportunities in order to manage chronic comorbid conditions. We conducted a cross-sectional examination of the relationships between sociodemographic and biomedical characteristics to park proximity among 635 individuals receiving outpatient HIV care. The data collected included HIV-related biomarkers, depression, and diagnoses of other chronic diseases. The total acres of parks an individual is exposed within one-quarter mile from their home were assessed. The cohort included 635 individuals (67% men, 73% black, and 21% white, mean age 42 years). Unemployment was negatively associated with park availability. Park proximity was not associated with depression or HIV biomarkers. As yet, little effort has been committed to promoting park usage as a low-cost, sustainable method to addressing comorbidities among individuals with HIV.
We followed 205 HIV-infected adults on antiretroviral therapy for at least 12 weeks in a Gambian clinic, where routine viral load monitoring was performed. The 1- and 4-week self-reported adherence and timeliness in keeping to scheduled appointments were recorded at each visit. Seventy patients had measurable viremia between the 12th week and the 3rd year of therapy. Survival analysis of the first detectable viral load on therapy demonstrated an association with 4-week (hazard ratio [HR] 2.6, 95% confidence interval [CI] 1.5-4.3, P = .001) and 1-week (HR 1.9, 95% CI 1.1-3.3, P = .024) self-reported suboptimal adherence and with 1 to 15 days of late presentation for appointments (HR 1.6-1.8, P .027-.109). In a multiple regression model, only 4-week self-reported adherence remained as a significant predictor of viremia.
Tuberculosis (TB) remains the most common cause of death in people living with HIV/AIDS. The aim of the present study was to identify predictors of mortality in TB-HIV-coinfected patients.
We conducted an unmatched case–control study among a cohort of TB-HIV-coinfected adults who were on antiretroviral therapy (ART). Cases comprised 69 TB-HIV-coinfected patients who died during this period. For each case, we selected 3 (207) TB-HIV-coinfected patients who were alive during the end of the follow-up period.
Male sex (odds ratio [OR] = 2.04, 95% confidence interval [CI]: 1.04-4.02), being bedridden at enrollment (OR = 2.84, 95% CI: 1.17-6.89), and cough of more than 2 weeks during initiation of ART (OR = 4.75 95% CI: 2.14-10.56) were the best predictors of mortality among TB-HIV-infected patients.
Mortality among TB-HIV-coinfected patients accounted for a considerable number of deaths among the cohort. Patients with cough at ART initiation and with poor functional status should be strictly followed to reduce death.
We determined the proportion and correlates of self-reported pregnancy planning discussions (that is preconception counseling) that HIV-positive women reported to their family physicians (FPs), HIV specialists, and obstetrician/gynecologists (OB/Gyns).
In a cross-sectional substudy, HIV-positive women of reproductive potential were asked whether their care providers discussed pregnancy planning. Logistic regression was used to calculate odds ratios for the correlates of preconception counseling.
A total of 431 eligible participants (median age 38, interquartile range = 32-43) reported having discussion with a physician (92% FP, 96% HIV specialists, and 45% OB/Gyns). In all, 34%, 41%, and 38% had their pregnancy planning discussion with FP, HIV specialist, and Ob/Gyns, respectively; 51% overall. In the multivariable model, significant correlates of preconception counseling were age (P = .02), marital status (P < .01), number of years living in Canada (P < .001), and age of youngest child (P < .01).
Preconception care in our cohort was suboptimal. We recommend that counseling on healthy preconception should be part of routine HIV care.
To evaluate the trends in abacavir (ABC) prescription among antiretroviral (ARV) medication-naive individuals following the presentation of the Data Collection on Adverse Events of Anti-HIV Drugs (DAD) cohort study.
We conducted a retrospective cohort study of ARV medication-naive individuals in the Canadian Observational Cohort (CANOC).
Between January 1, 2000, and February 28, 2010, a total of 7280 ARV medication-naive patients were included in CANOC. We observed a significant change in the proportion of new ABC prescriptions immediately following the release of DAD (–11%; 95% confidence interval [CI]: –20% to –2.4%) and in the months following the presentation of these data (–0.66% per month; 95% CI: –1.2% to –0.073%). A post-DAD presentation decrease in the odds of being prescribed ABC versus tenofovir (TDF) was observed (adjusted odds ratio, 0.72 per year, 95% CI: 0.54-0.97).
Presentation of the DAD was associated with a significant decrease in ABC use among ARV medication-naive, HIV-positive patients initiating therapy.
Pain, sleep, and functional disturbances are a common occurrence in people living with HIV/AIDS-related distal sensory peripheral neuropathy (PLWHA-DSPN) yet lack group classification and quantification.
A total of 46 PLWHA-DSPN were recruited, as part of a 2-group intervention study, to complete the Neuropathic Pain Scale and the Pittsburgh Sleep Quality Index (PSQI) questionnaires. The participant’s performance during a forward reach task and walking distance in 6 minutes was recorded as a measure of function.
The pain (60.77 ± 17.85) and sleep (14.62 ± 4.28) scores denote marked pain and sleep disturbances, compared to sero-negative, age-matched individuals. The ambulation distance was limited (243.99 ± 141.04 m) and inversely associated with the PSQI-sleep efficiency subscale (rs = –.35, P < .05). The average reaching distances measured (36.07 ± 7.37 cm) were similar to sero-negative, age-matched individuals. Pain, sleep, and functional measures exhibited significant associations.
The data collected suggest that PLWHA-DSPN report moderate-to-severe pain and significant sleep disturbances and exhibit limited ambulation distances.
Alcohol use is common among people with HIV, and beliefs about alcohol interactions with medications predict decreased medication adherence, risking drug-resistant mutations. Maraviroc is an HIV entry inhibitor approved for treatment of both drug-sensitive and drug-resistant HIV strains. The present study evaluated the effects of alcohol on maraviroc pharmacokinetics and the effects of maraviroc on alcohol pharmacokinetics.
Ten healthy adults completed alcohol (1 g/kg) and placebo alcohol pharmacokinetics sessions before and after 7 days of maraviroc administration.
Alcohol concentrations increased 12% following maraviroc. Maraviroc pharmacokinetics were unaffected by alcohol.
Maraviroc treatment should not be interrupted if alcohol is consumed.
Postnatal depression (PND) is a major problem in low- and middle-income countries (LMICs). A total of 210 postpartum mothers attending primary care urban clinics were screened for PND at 6 weeks postpartum using the Edinburgh Postnatal Depression Scale (EPDS) and Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition; DSM-IV) criteria for major depression. The HIV prevalence was 14.8%. Of the 210 enrolled postpartum mothers, 64 (33%) met DSM IV criteria for depression. Using trained peer counselors, mothers with PND (n = 58) were randomly assigned to either group problem-solving therapy (PST, n = 30) or amitriptyline (n = 28). Of the 58 mothers with PND, 49 (85%) completed 6 weeks of group PST (n = 27) or pharmacotherapy (n = 22). At baseline, the mean EPDS score for participants randomized to group PST was 17.3 (standard deviation [SD] 3.7), while the group randomized to amitriptyline had a mean EPDS score of 17.9 (SD 3.9; P = .581). At 6 weeks postintervention, the drop in mean EPDS score was greater in the PST group (8.22, SD 3.6) compared to the amitriptyline group (10.7, SD 2.7; P = .0097). Group PST using peer counselors is feasible, acceptable, and more effective compared to pharmacotherapy in the treatment of PND. Group PST could be integrated into maternal and child health clinics and preventing mother-to-child transmission of HIV programs in LMICs.
High prevalence of vitamin D deficiency among HIV-infected individuals has been reported in many studies. Increasing evidence for vitamin D’s role in innate and cell-mediated immunity suggests that vitamin D insufficiency or deficiency is worrisome particularly for HIV-infected individuals who are already at increased risk of infection. It is unknown whether vitamin D deficiency and supplementation will have any effects on HIV infection, including CD4 counts/CD4% and HIV plasma RNA.
Serum vitamin D levels, 25-hydroxyvitamin D (25-(OH)D), were obtained from 160 HIV-infected youth, aged 2 to 26 years as part of routine care. The HIV plasma RNA and CD4 counts were compared between patients with normal vitamin D and vitamin D insufficiency/deficiency. Individuals whose vitamin D level was ≤35 ng/mL received vitamin D3 supplementation. We compared the HIV plasma RNA, absolute CD4 counts, and CD4% in pre– and post–vitamin D supplementation. Categorical comparisons between the groups were examined using a nonparametric Fisher exact test, while continuous variables, pre– and post–vitamin D supplementation, were examined using a parametric paired samples t test.
The majority (152 of 160; 95%) of our patients were African American. Only 8 (5%) of 160 had normal vitamin D. Of the 160 patients with HIV, 37 (23.1%) had vitamin D insufficiency (25-(OH)D level between 21 and 35 ng/mL) and 11 of 160 (71.9%) had vitamin D deficiency (25-(OH)D level ≤20 ng/mL). Absolute CD4 counts averaged lower in patients who have severe vitamin D deficiency (25-(OH)D ≤10 ng/mL; mean 574.41 ± 306.17 cells/mm3) compared to those who had higher vitamin D level (mean 701.15 ± 444.19 cells/mm3). The CD4% were also lower (mean 25.12% ± 12.5%) in those who have severe vitamin D deficiency compared to those whose vitamin D level was ≥11 ng/mL (mean 29.47% ± 11.62%). The HIV plasma RNA was similar in all the groups. Our patients who were prescribed tenofovir (TDF) and/or efavirenz (EFV) did not have different vitamin D levels than patients who were prescribed other antiretroviral (ARV) medications. Only 60 (39.5%) of the 152 patients who received vitamin D supplement showed improvement in vitamin D level. Of the 60 patients, 10 (16.7%) had normalized vitamin D level (25-(OH)D level > 35 ng/mL). We did not see any significant change in the absolute CD4 counts or CD4%.
A higher prevalence of vitamin D insufficiency/deficiency was found in our study compared to the previous large cohorts. However, patients who were prescribed TDF/EFV did not have lower vitamin D levels. Inadequate sunlight exposure in temperate latitudes and the cloud effect of the Great Lakes as well as large number of African American participants who live in the inner city area with poverty and poor diet may combine to explain these results. The effect of ARV medications on vitamin D may be washed out by the numerous other factors affecting vitamin D in our patients. Severe vitamin D deficiency seemed to be related to lower CD4 counts and CD4% but not related to HIV plasma RNA. Vitamin D supplementation did not increase CD4 counts/CD4% in our study.
The purpose of this study was to evaluate the prevalence of depressive symptoms and associated variables among people living with HIV/AIDS (PLWHA) in a specialized treatment center in a city located in southern Brazil. A cross-sectional study was conducted using the Beck Depression Inventory to assess the presence of depressive symptoms. The prevalence of depressive symptoms was 53.5% among the surveyed population, which supports the idea that depressive symptoms are more common among PLWHA, mainly if compared with the general population. It was observed that 57.7% of the study participants were with depressive symptoms and did not take any psychiatric medication and 100% did not undergo psychotherapy, which indicates undertreatment. There was no statistically significant difference in the mean CD4 count between patients with depressive symptoms (484.1 ± 353) and patients without depressive symptoms (528.4 ± 263). Further actions should be taken to improve the care for PLWHA. The interface between psychology, psychiatry, and internal medicine is of utmost importance to provide a more humanized care, in which the psychosocial, psychological, and psychiatric aspects are not neglected.
Pegylated interferon (PEG-IFN)/ribavirin (RBV)-related cytopenias have been associated with improved virological outcomes among hepatitis C virus (HCV)-monoinfected patients. This analysis evaluated PEG-IFN/RBV-related cytopenias with virological responses among HIV/HCV-coinfected patients.
Pooled data from PARADIGM and AIDS Pegasys Ribavirin International CO-infection Trial (APRICOT) trials of HIV/HCV-infected patients treated with PEG-IFN/RBV. Virologic response was categorized as HCV RNA detectable (end of treatment nonresponders [ET-NR]) or nondetectable (end of treatment responders [ETR]). Declines in hemoglobin (Hgb), platelets, neutrophils, lymphocytes, and weight between the groups were compared via analysis of covariance and Cochran-Mantel-Haenszel test.
A total of 474 patients, 291 ET-NR and 183 ETR (67 relapsers, 116 with sustained virologic response), 81% male, 52% Caucasian, 88% noncirrhotic, and 67% nondetectable HIV. The ETR experienced greater Hgb declines (≥3.0 g/dL) from baseline (73.8% versus 55.0%; P < .0001), neutrophils ≤1 and ≤ 0.5 x 109/L (66.1% versus 56.4%; P = .0334 and 42.6% versus 33.3%; P = .0312, respectively), and lymphocytes ≤1.5 and ≤0.5 x 109/L (99.5% versus 87.6%; P < .0001 and 24.6% versus 14.9%; P =.0079, respectively).
The HIV-/HCV-coinfected patients with ETR experienced greater declines in Hgb, neutrophils, and lymphocytes than the ET-NR patients.
HIV care providers in the United States must counsel clients about disclosure to sexual partners and report anyone who is suspected of noncompliance. This study compared provider attitudes and practices in relation to counseling clients about mandatory disclosure in North Carolina and Alabama, the 2 states with similar HIV epidemiology but different laws for HIV control. Personal interviews were conducted with 20 providers in each state (n = 40). The results were analyzed in a qualitative, cross-comparison method to identify patterns of convergence or difference. Providers in both states believed that clients often failed to notify sexual partners and were secretive if questioned about disclosure. Differences in counseling styles and procedures for each state were noteworthy. Compared to Alabama, North Carolina had harsher penalties for nondisclosure, stricter and more standardized procedures for counseling, and providers expressed greater support for HIV criminalization. Although most North Carolina providers viewed the stricter standards as beneficial for HIV care and control, Alabama providers were likely to view such standards as a barrier to patient care. These results indicated a direct relation between state HIV law, provider attitudes, and counseling procedures for mandatory disclosure.
A 44-year-old HIV-infected male, having a low CD4 count, was on antiretroviral therapy for the last 2 months, when he developed a skin rash. He gave a history of solitary unprotected extramarital sexual contact 6 months before onset of the rash. Dermatological examination revealed a bilaterally symmetrical, maculopapular erythematous rash involving the palms, forearms, and neck. He showed a positive sign of Buschke-Ollendorff. In the meanwhile, the CD4 count had improved to 196 cells/mm3 from the previous count of 92 cells/mm3 and the viral load had decreased. Serum venereal disease research laboratory (VDRL) test was reactor at 1:64. He was found to be positive result for treponema pallidum hemagglutination test. Skin biopsy revealed features of secondary syphilis. The rash responded well to a single injection of benzathine penicillin, resulting in the lowering of the VDRL titers. There was no evidence of neurosyphilis. This is a very rare instance of secondary syphilis manifesting as immune reconstitution syndrome in an HIV-positive patient.
The article reports on the aspects of a Botswana Ministry of Education and Skills Development (MoE & SD) HIV/AIDS Instructional Television (ITV) project modeled on a similar HIV/AIDS program implemented in Brazil. This Teacher Capacity Building Project (TCBP) in Botswana is in its initial years of implementation. Its overall goal is to contribute to the prevention and mitigation of the impact of HIV and AIDS by strengthening the capacity of the education and communication sectors to deliver interactive, distance HIV/AIDS education primarily to teachers so that they act as agents of behavior change among the in-school youth. One of the components of the TCBP program is a live teacher education television HIV/AIDS program called Talk Back program. Talk Back is a collaborative effort of the MoE & SD and the Botswana national television station. The Talk Back program involves development and implementation of weekly 1 hour live HIV/AIDS education interactive TV broadcasts for teachers. The development of the live programs is guided by a curriculum that provides a wide range of themes related to HIV/AIDS and education. This article reports the results of a survey of a sample of teachers and students at junior secondary schools and senior secondary schools, first, on their views and opinions regarding the Talk Back program as a TCBP. Second, how Setswana cultural beliefs, myths, and practices on sexuality affect teachers' and adolescents’ sexual decisions, practices, and experiences as well as HIV&AIDS/sexually transmitted infection prevention. A questionnaire survey and focus group interviews were used as data collection instruments in selected secondary schools. The findings of the study suggest that the Talk Back program has not met much success as a TCBP. The findings further suggest that several myths, beliefs, misconceptions, and attitudes about HIV/AIDS exist among Botswana teachers and students and thus make it difficult for the Talk Back program to impart the HIV/AIDS message successfully. Therefore, there is a need for more stakeholders in HIV/AIDS education, where appropriate learning techniques are used, to bring about the desired behavioral change.
Seven rapid diagnosis tests (RDTs) of HIV were evaluated by a panel group who collected serum samples from patients in Abidjan (HIV-1 = 203, HIV-2 = 25, HIV-dual = 25, HIV = 305). Kit performances were recorded after the reference techniques (enzyme-linked immunosorbent assay). The following RDTs showed a sensitivity of 100% and a specificity higher than 99%: Determine, Oraquick, SD Bioline, BCP, and Stat-Pak. These kits were used to establish infection screening strategies. The combination with 2 or 3 of these tests in series or parallel algorithms showed that series combinations with 2 tests (Oraquick and Bioline) and 3 tests (Determine, BCP, and Stat-Pak) gave the best performances (sensitivity, specificity, positive predictive value, and negative predictive value of 100%). However, the combination with 2 tests appeared to be more onerous than the combination with 3 tests. The combination with Determine, BCP, and Stat-Pak tests serving as a tiebreaker could be an alternative to the HIV/AIDS serological screening in Abidjan.
HIV infection has changed the scenario of infectious disease. HIV-associated immunodeficiency resulted in a wide spectrum of new opportunistic infections. After introduction of antiretroviral therapy (ART), immune reconstitution inflammatory syndrome (IRIS) became an important challenge in management of 10% to 25% of the patients. Meta-analyses of IRIS from various reports published worldwide by Monika Muller et al described 12% IRIS incidence and 15.7% IRIS tuberculosis. Among IRIS tuberculosis, central nervous system involvement with IRIS tuberculous meningitis forms only 7%. Only 9 cases of tuberculous brain abscess is reported in patients with AIDS so far. The IRIS tuberculous brain abscess is very rare, and so far only 1 case is reported as a paradoxical reaction after ART initiation. Here, we report a case of recurrent IRIS tuberculosis meningitis and brain abscess.
The effects of previous alcohol abuse on antiretroviral therapy (ART) adherence have been less studied.
Participants were randomized to a 3-month group intervention or an individual-enhanced standard-of-care condition and assessed over 6 months. Individual assessment at baseline, 3, and 6 months was done; interviews included lifetime history of problematic alcohol use.
A total of 80 HIV-positive individuals on ART were recruited. In all, 35% of participants reported a history of problematic alcohol use, 37% had a detectable viral load, 55% were nonadherent, and 24% reporting skipping medication in the previous 3 months. There was no association between a history of problematic use and an adherence at any time point, that is, at baseline (t = –.7, P = .47), midpoint (t = –.39, P = .69), and 6-month follow-up (t = –1.2, P = .23).
Results suggest that a history of problematic alcohol use may not impact ART adherence.
Coinfection with HIV and hepatitis B virus (HBV) is common in resource-limited settings but is frequently not diagnosed. The authors retrospectively tested specimens for HBV in HIV-infected Thai women who had participated in an antiretroviral therapy (ART) clinical study. A substantial proportion (27 of 211; 13%) of HIV-infected women were HBV coinfected. Among HIV/HBV-coinfected women, the authors observed similar rates of antiretroviral-associated liver toxicity (despite nevirapine [NVP] use) and CD4 count reconstitution as observed in HIV-monoinfected women. Hepatitis B surface antigen (HBsAg) screening detected the majority (81%) of HBV coinfections, including all 5 HBV-coinfected women who did not suppress HBV despite 48 weeks of lamivudine (3TC)-containing ART and could be used to tailor ART for patients diagnosed with HBV coinfection in accordance with World Health Organization guidelines. Although HBsAg screening did not diagnose 5 occult HBV coinfections, these women achieved HBV suppression on 3TC-containing ART, suggesting that not detecting occult HBV coinfection would have limited clinical impact.
The purpose of this study was to identify obstacles health care workers face in providing care for people living with HIV and AIDS (PLWHA). Based on these findings, health authorities can design interventions to support health care workers in providing better medical care for PLWHA. Thirty in-depth interviews were conducted with physicians and nurses in one 300-bed tertiary care public hospital in Giza, Egypt. Thematic analysis was conducted by 2 investigators. Five main themes were identified (1) fear of infection; (2) disbelief in effectiveness of infection control measures to protect against HIV; (3) misconceptions regarding medical care for PLWHA; (4) fear of secondary stigma; and (5) moral judgments toward PLWHA and negative connotations related to HIV. Interventions targeting health care workers should be multidimensional, including knowledge and skills building as well as value and attitude change. Reducing stigma among health care workers will improve access to care for PLWHA.
This cross-sectional study aimed at determining the prevalence and risk factors for severe anemia, severe microcytic anemia, and severe normocytic anemia among HIV-infected individuals aged >15 years. Univariate and multivariate analyses were performed to identify the risk factors for anemia.
Data from 40 408 patients were analyzed, showing an overall prevalence of 22% for severe anemia. The risk of developing severe anemia increased by 49% among patients with a body mass index of <18.5 kg/m2, by approximately 2-fold among patients with the World Health Organization (WHO) stage III, and by 3-fold among patients with WHO stage IV illness. Severe normocytic anemia was uniquely increased among patients aged ≥50 years, among those with chronic diarrhea and Kaposi sarcoma, and those taking cotrimoxazole.
There was a high prevalence of severe anemia among adults infected with HIV. Focused identification of anemia should be based on the hemoglobin and mean corpuscular volume measurements.
Despite numerous potential health outcomes of dog guardianship, their value has not been examined in the HIV-positive population. The study objective was to examine the relationship between dog guardianship and HIV clinical outcomes (antiretroviral adherence [≥95% versus <95%], HIV viral load [≥48 versus <48 copies/mL], and CD4 count) among HIV-positive individuals. The authors conducted a secondary analysis of baseline data of 370 HIV-positive men on antiretroviral regimen enrolled in the Duo Project. Generalized estimating equations were used for inferential regression analyses, while controlling for the focal dog guardianship variable and nonfocal covariates. Current dog guardianship was reported in 28.7% of participants. Dog guardianship may be associated with higher CD4 (coefficient = 60.6, P = .052) and adherence ≥95% (odds ratio [OR] = 1.80, P = .048); however, having a detectable viral load was not related to dog guardianship (OR = 0.94, P = .85). Further clinical research with detailed dog guardianship data is needed to further examine the association between dog guardianship and HIV clinical outcomes.
Triamcinolone is a long-acting glucocorticoid medication that can be responsible for transient suppression of the hypothalamic–pituitary–adrenal (HPA) axis. This physiologic alteration may persist for weeks after repeated or even single localized injection of this agent. However, when this glucocorticoid agent is given to patients receiving the HIV protease inhibitor (PI) ritonavir (RTV), inhibition of their shared cytochrome P450 3A4 degradation pathway leads to an increased bioavailability of triamcinolone, with subsequent heightening and prolongation of the glucocorticoid serum levels. In those instances, iatrogenic Cushing syndrome may ensue. The authors encountered such an event in an HIV-infected patient on chronic treatment with an antiretroviral regimen containing RTV. The patient’s clinical presentation and laboratory investigations confirmed a diagnosis of Cushing syndrome and secondary adrenal insufficiency. This was believed to have occurred in close association following cervical vertebral column facet joint injections with triamcinolone acetonide for cephalagia deemed related to cervical spine disease. The discontinuation of the RTV-boosted PI therapy alone, promoting the clearance of the elevated triamcinolone serum levels and restoration of HPA homeostasis, proved successful in this patient. For this case, the authors review the published English medical literature relating to this uncommon phenomenon.
We report on a case of severe cutaneous reaction to darunavir/r and a successful desensitization protocol. The patient was a 41-year-old female, known to be HIV infected for 18 years and who had received several drug regiments in the past. As a consequence, her virus had triple-class mutations but was susceptible to darunavir/r. Her CD4 was 200 cells/mm3 and HIV viral load 56,000 copies/mL. Eight days after initiation of darunavir/r the patient developed a severe pruritic vesicular extended cutaneous allergic reaction which required cessation of all drugs. Due to the severity of the allergic reaction no rechallenge was done. After the patient's recovery, the virus was found to be susceptible only to maraviroc, raltegravir, and darunavir/r. Since darunavir/r was an essential component in treating this triple-class mutated virus, a desensitization protocol was applied successfully. Six months after desensitization, the patient is asymptomatic, compliant, and her HIV viral load remains at <20 copies/mL.
Despite the widespread availability of prevention of mother-to-child transmission (PMTCT) programs, many women in sub-Saharan Africa do not participate in PMTCT. This pilot study aimed to utilize partner participation in an intervention to support PMTCT uptake.
Couples (n = 239) were randomized to receive either a comprehensive couples-based PMTCT intervention or the standard of care.
Compared to the standard of care, participants receiving the intervention increased HIV- and PMTCT-related knowledge (F 1,474 = 13.94, p = .004) and uptake of PMTCT, as defined by infant medication dosing (74% vs. 46%, 2 = 4.69, p = .03).
Results indicate that increasing male attendance at antenatal clinic visits may be "necessary but not sufficient" to increase PMTCT uptake. Increasing HIV knowledge of both partners and encouraging active male participation in the PMTCT process through psychoeducational interventions may be a strategy to increase the uptake of PMTCT in South Africa.
Current strategies are insufficient to contain the growing tuberculosis (TB) epidemic in areas of high HIV prevalence such as sub-Saharan Africa. Due to the increased risk of morbidity and mortality among those coinfected, early detection is critical. However, strategies dependent on passive, facility-based case finding have failed due to severe limitations in the HIV-positive population. There is growing evidence from multiple clinical trials that early initiation of antiretroviral therapy (ART) in patients coinfected with HIV and TB reduces mortality. Integration of community-based distribution of ART and TB medicines should be considered for coinfected patients to help improve retention in care and to off-load busy health systems. Several models of integration of HIV and TB care in sub-Saharan Africa have been successful. This review article examines the concepts of HIV and TB integration of testing and treatment at the community level.
The study sought to describe the quality-of-life impairments in newly diagnosed HIV/AIDS-infected adult patients with cutaneous lesions. This was a hospital-based, cross-sectional, descriptive study of 160 newly diagnosed HIV/AIDS-infected adult patients attending the HIV/AIDS clinic of University of Ilorin Teaching Hospital (UITH). Systemic random sampling technique was used in recruiting respondents for the study. The Dermatology Life Quality Index (DLQI) was used to gauge the quality-of-life impairments. The study showed high prevalence of cutaneous lesions in HIV/AIDS-infected patients. Majority of the respondents (83.7%) scored more than 10 in DLQI score. This signifies that the skin lesions had large negative effects on their quality of life. The assessment of the impact of dermatoses on patients’ quality of life is important for clinical management. It is pertinent to detect patients at higher risk of experiencing worse quality of life in order to treat them holistically.
Health care providers (HCPs) serving HIV-infected patients, especially in rural and underserved areas, have limited access to continuing medical education.
To identify subgroups of HCPs who might benefit from a telehealth training program focusing on HIV/AIDS care based on HCPs’ objective for attending the training.
Hierarchical cluster analysis combined with thematic analysis identified the subgroups.
A total of 56 HCPs attended between 1 and 9 of the 12 sessions conducted (mean 2, standard deviation = 1.6). Subgroups identified included knowledge (HCPs interested in gaining, increasing, or updating their knowledge in HIV care), learn–expert (HCPs interested in learning, obtaining, or providing expert opinion), and observe–apply–network (HCPs interested in observing the training, applying knowledge gained to practice, and networking). No group differences were found in the participants’ reaction to the session, change in knowledge following the training, and other important characteristics.
Methodological contributions of the study are discussed.
Renal insufficiency has been shown to be a significant, independent risk factor for mortality among HIV-infected patients. Unfortunately, little is known about the prevalence and nature of renal impairment in African populations initiating antiretroviral treatment. This study aims to find the prevalence of abnormal renal function among antiretroviral therapy (ART)-naive, HIV-infected patients in the South Eastern geopolitical zone of Nigeria.
This is a cross-sectional hospital-based study, involving 300 ART-naive HIV-positive patients, seen over a 1-year period, aged from 18 years and older, presenting to the clinic for the first time.
A total of 300 patients were included in the study, 104 (34.7%) males and 196 (65.3%) females. The prevalence of significant renal disease was 24.3% (73 of 300), while 38.3% (115 of 300) had mild renal impairment. Using logistic regression, age, CD4 count, urea, creatinine, and hemoglobin were significantly associated with renal impairment.
The authors observed a high prevalence of significant renal impairment among HIV-infected patients at the time of ART initiation.
It is unclear whether HIV-related factors modify risk of hypertension (HTN). In a cohort of patients with AIDS, the authors determined HTN incidence and prevalence and assessed associated traditional, HIV-specific, and retinal vasculature factors.
Prospective observational cohort included 2390 patients with AIDS (1998-2011). Univariate analysis was used to assess the impact of traditional- and AIDS-related risk factors for HTN prevalence and incidence. Multivariate regression analyses were used to evaluate the adjusted impact of these factors.
Hypertension prevalence was 22% (95% confidence interval [CI] 21%-24%) and was associated with traditional HTN risk factors (age, black race, and higher weight) as well as diabetes, hyperlipidemia, time since AIDS diagnosis, and higher CD4 counts. Hypertension incidence was 64.1 per 1000 person-years (95% CI 58.7/1000-69.9/1000). Age, race, weight, and diabetes were associated with incident HTN but HIV-specific factors were not.
Hypertension, a prevalent cardiovascular risk factor in patients with AIDS, is associated with traditional and metabolic risk factors.
The purpose of this study was to evaluate how poor retention in HIV care impacts time to viral suppression after initiating highly active antiretroviral therapy.
A retrospective cohort study design, employing a medical chart review, was conducted at an academic infectious disease clinic at the University of Kentucky. Patients seeking care between 2003 and 2011 were included in the study. A log-normal model was employed to determine the factors associated with time to viral suppression.
Of the 532 patients in the study, 426 (80.1%) patients were virally suppressed. Controlling for insurance status, race, baseline CD4 counts, and viral loads, the expected time to viral suppression for nonoptimal retainers was longer compared to optimal retainers (100% retained in care; time ratio: 2.04; 95% confidence interval: 1.40-2.90).
Researchers should continue to study the impact of retention on clinical outcomes and strategies to improve retention and reengage those lost to follow-up back into care.
Early use of highly active antiretroviral treatment (ART) in people living with HIV for HIV prevention has gained legitimacy but remains controversial. Nineteen French HIV experts with diverse specializations (over half of whom were clinicians) were qualitatively interviewed on their views about ART irrespective of CD4 count of more than 500 cells/mm3 for purposes of HIV prevention, which is not systematically recommended in France. Content analysis identified 2 broad categories: individual considerations (subcategories: patient health and well-being; patient preparedness and choice) and collective considerations (subcategories: HIV transmission risk; impact on the epidemic; cost). Uncertainty surrounded many experts’ considerations, and unity was lacking on key issues (eg, candidacy for early preventive treatment, expected clinical- and population-level effects). An umbrella theme labeled "Weighing the merits of early ART in the face of uncertainties" was identified. Our analyses raise doubts about the current acceptability of widespread implementation of early ART for HIV prevention in France.
Difficulties in systematically monitoring HIV viral load in resource-limited settings prompt the search for alternate approaches. The authors aimed at assessing the correlation between the plasma levels of soluble forms of Fas receptors (Fas) and Fas ligands (FasL) with standard indicators of HIV disease progression in children.
Twenty-two HIV-1-positive children were enrolled in Yaounde. CD4 counts, CD4% counts, plasma levels of Fas, FasL, and HIV-1 RNA levels were assayed.
The correlation coefficients (P values) between FasL levels and each of HIV-1 viral load, CD4 counts, and CD4% were, respectively, .56 (.01), –.29 (.18), and .30 (.18). On the other hand, the respective correlation coefficients (P values) with Fas levels were .12 (.60), –.30 (.18), and –.29 (.19).
The significant correlation between levels of HIV-1 viral load and FasL suggests that the latter needs to be further studied as a potential biomarker to monitor HIV-1 disease progression in children in resource-limited setting.
The purpose of this study was to assess patients’ experience and satisfaction with pharmacy-only refill program (PRP) and to compare those who were removed from the PRP with those still in the program.
A sample of 446 patients was selected from 1503 patients on antiretroviral therapy that had been enrolled in the PRP for at least 24 months. The study used interviewer-administered questionnaires to assess patients’ experience and satisfaction with PRP.
Of the 446 patients, 133 (29.8%) were removed from the PRP. By multivariate analysis, it was found that wanting to see a clinician before their scheduled clinic visit, Christian religion, and not understanding why they were enrolled in PRP were associated with having been removed from the PRP. Patients felt that the greatest benefit from the program was the time that they saved to do other activities. Patients preferred to collect their medication every 3 months instead of every month.
All patients interviewed scored the program high, and all recommended that the PRP should continue. Stable patients prefer to see clinicians less frequently and visit clinic less often.
Goals of universal "test and treat" will never be fully realized if testing acceptance remains low, including rural areas, where HIV is increasingly recognized. We surveyed 250 randomly selected households from a rural Ethiopian town (Arba Minch) and surrounding villages about HIV testing experience, knowledge, and attitudes. Of the 558 adults, 45% were never HIV tested. Those never tested for HIV were more likely to be (P < .05) ≥45 years, rural villagers, and unaware of the benefits of antiretroviral therapy treatment and that persons with HIV can appear healthy; they were more likely to believe HIV-infected persons would be stigmatized and unsupported by their communities. Of those never tested, 70% were interested in HIV testing if offered. Despite recommendations that all persons be HIV tested, almost half of the adult residents in this rural community were never tested. Programs to increase HIV testing must include measures to address stigma/discrimination and knowledge deficits including benefits of early diagnosis and treatment.
Little is known about HIV-infected patients with serum testosterone levels in high normal to elevated ranges. An HIV-infected patient with hepatitis C and unexplained high serum testosterone levels prompted a retrospective chart review into the association of hepatitis C and serum testosterone levels greater than 1000 ng/mL in our clinic. The charts of 1419 male HIV patients were reviewed. Out of 1419 patients, 159 (11%) met the criteria for data analysis. A total of 8 patients had serum testosterone levels greater than 1000 ng/mL. There was no significant correlation between hepatitis C antibody positivity or presence of hepatitis C viremia as measured by viral load, nor was there any significant correlation with CD4+ cell counts. We found a weak positive association between years since reported diagnosis of HIV and high testosterone levels.
There is a paucity of research demonstrating how HIV-funded services in Africa have improved equity and access to non-HIV services for both HIV-infected and uninfected patients. In this short communication, we describe the impact of an airborne outreach program to provide HIV services to high-HIV burden health facilities in rural Botswana. The analysis demonstrates how this HIV-funded program enhanced access to essential subspecialist services at several rural health facilities across Botswana.
The counselors’ form the backbone of HIV/AIDS control program, and for voluntary counseling and testing services to be effective counselors’ opinions are crucial.
To assess the perceptions of integrated counseling and testing center (ICTC) counselors with respect to the training received, problems faced in providing services, and job satisfaction.
Qualitative methods such as 1 focus group discussion and 7 in-depth interviews were conducted among 14 counselors employed at 13 ICTCs in a costal district of south India.
The counselors identified the need for improving refresher training; job perception and satisfaction among counselors was found to be poor; issues such as shared confidentiality and targets for counseling were perceived to affect the ICTC services.
The issues identified by counselors such as problems related to refresher training, targets set for counseling and testing, the pay scale and shared confidentiality should be addressed for better service delivery.
HIV disease progression is associated with declining quality of life and overall health status, although most research in this domain has been conducted among Western populations where B is the infecting clade. This study sought to determine the effects of early-stage clade-C HIV infection (CD4 count ≥400 cells/mm3) on neurocognitive functioning, cognitive depression, and fatigue by comparing a matched sample of HIV-positive and HIV-negative Northern Indians. This study also examined the impact of these factors on quality of life within the HIV-positive individuals. HIV-positive participants demonstrated reduced cognitive functioning, increased fatigue, and lower quality of life. Fatigue and cognitive impairment interacted to negatively impact quality of life. Results suggest that early-stage HIV clade-C-infected individuals may experience subclinical symptoms, and further research is needed to explore the benefit of therapeutic interventions to ensure optimal clinical outcomes and maintain quality of life in this vulnerable population.
Lipodystrophy is a known adverse effect of highly active antiretroviral therapy (HAART). Lipodystrophy resulting in body dysmorphism can lower the quality of life (QoL) among HAART recipients. The main aim of our study was to find the effect of lipodystrophy on QoL among people living with HIV/AIDS (PLHIV) on HAART.
This cross-sectional study was conducted in a tertiary care hospital in south India. The participants were assessed for the presence of lipodystrophy. Their QoL was assessed using HIV-AIDS-targeted QoL questionnaire (HAT-QoL). Statistical analysis was carried out using SPSS version 11.5.
Lipodystrophy was present in 21 participants (42%). The QoL among individuals with lipodystrophy was found to be significantly lower in terms of disclosure worries (P = .023) and financial worries (P = .049).
Lipodystrophy adversely affects QoL among PLHIV. There is a need for studies analyzing factors that can potentially improve the QoL in such individuals.
The sustainability of donor-supported cervical cancer screening for HIV-positive women in underresourced setting is a concern. The authors aimed to determine the willingness of HIV-positive women for out-of-pocket payment for the cancer screening, if necessary.
Questionnaires were administered to 400 HIV-positive women at the Adult HIV clinic, University of Nigeria Teaching Hospital (UNTH), Enugu, Nigeria.
In all 11 (2.8%) respondents were aware of Pap smear, but only 1 (9.1%) of them had used it. After cervical cancer screening counseling, 378 (94.5%) respondents were willing to pay for Pap smear, irrespective of the cost. This willingness showed no trend across marital or educational groups. Younger age of respondents was not associated with willingness to pay for Pap smear (odds ratio = 1.24; confidence interval 95%: 0.52, 2.94).
Willingness to pay for Pap smear by HIV-positive women in Enugu, Nigeria, is high. This has implication for the program sustainability.
We conducted a study to investigate HIV and hepatitis delta virus (HDV) coinfection among patients with chronic hepatitis B virus (HBV) infection and the triple infection’s (HIV/HBV/HDV) clinical implications in India, an intermediate HBV endemic region, with an estimated HIV-positive population of 2.5 million. A total of 450 patients (men: 270; women: 180) with chronic HBV infections and 135 healthy volunteers were screened for HIV and HDV. The incidence of the triple infection was low (4 [0.8%]) compared with dual infections of HIV-1/HBV (7 [1.5%]) and HBV/HDV (22[4.8%]). Among 21- to 40-year-olds, HBV/HDV coinfection (45.8%) and HBV/HDV/HIV-1 triple infection was predominant (75%). Among 11 patients coinfected with HIV-1/HBV, 4 (36%) were tri-infected and were also associated with chronic hepatitis and cirrhosis. The HDV coinfection was higher among patients coinfected with HBV/HIV-1, despite the declining trend in HDV infection among HIV-negative patients, as previously reported. Thus, it is important to assess the impact of HIV, chronic HBV, and HDV tri-infection in India.
With effective highly active antiretroviral therapy (HAART), perinatally HIV-infected children are living longer through adolescence.
We conducted a cross-sectional study of perinatally HIV-infected adolescents, aged 11 to 18 years. Demographically matched controls were also enrolled. The adolescents completed the Youth Self-Report (YSR), while the caregivers filled out the Child Behavior Checklist (CBCL), to determine emotional and behavioral problems.
The sample included 50 HIV-infected adolescents and 56 controls. The internalizing problem scores from the YSR were significantly higher in the HIV-infected group than those in the control group (13.76 versus 9.95, P = .02). The total competence scores, from both the self-report and the caregiver report in the HIV-infected group, were significantly lower than those of the control group (P = .005 and .001).
Although HAART has prolonged the survival of HIV-infected children, they remain at increased risk of psychosocial problems as well as impaired social functioning.
Prior cross-sectional studies have found inconsistent relationships between body mass index (BMI) and disease progression in HIV-infected individuals.
Cross-sectional and longitudinal analyses were conducted on data from a sample of 864 HIV-infected men who have sex with men (MSM) obtained from a large, nationally distributed HIV clinical cohort.
Of the 864 HIV-infected MSM, 394 (46%) were of normal weight, 363 (42%) were overweight, and 107 (12%) were obese at baseline. The baseline CD4 count was 493 (standard error [SE] = 9), with viral load (log10) = 2.4 (SE = .04), and 561 (65%) were virologically suppressed. Over time, controlling for viral load, highly active antiretroviral therapy (HAART) adherence, age, and race/ethnicity, overweight and obese HIV-infected men possessed higher CD4 counts than that of normal weight HIV-infected men. Further, overweight and obese men possessed lower viral loads than that of normal weight HIV-infected men.
For HIV-infected MSM, in this longitudinal cohort study, possessing a heavier than normal BMI is longitudinally associated with improved immunological health.
With the advent of retroviral therapies, the incidence of severe dementia associated with HIV has been reduced, although minor neurocognitive impairment is being increasingly recognized in the course of illness. We report a case of a young woman presenting with HIV-associated dementia and raise awareness of its presentation in young age and as the first presenting symptom.
Activation of the hypothalamic–pituitary–adrenal axis, assessed in terms of cortisol levels, may enhance the ability of HIV to infect lymphocytes and downregulate the immune system, accelerating disease progression. This study sought to determine the effects of relaxation techniques on cortisol levels in HIV-sero-positive women.
Women (n = 150) were randomized to a group cognitive–behavioral stress management (CBSM) condition or an individual information condition and underwent 3 types of relaxation training (progressive muscle relaxation, imagery, and autogenic training). Cortisol levels were obtained pre- and postrelaxation.
Guided imagery was effective in reducing cortisol in the group condition (t = 3.90, P < .001), and muscle relaxation reduced cortisol in the individual condition (t = 3.11, P = .012). Among participants in the group condition attending all sessions, the magnitude of pre- to postsession reduction became greater over time.
Results suggest that specific relaxation techniques may be partially responsible for cortisol decreases associated with relaxation and CBSM.
Studies of sexual behavior among HIV-infected Thai youth show conflicting results due to the different ages of the respondents. This study examined the relationships between sexual self-efficacy and risk behaviors among 92 HIV-positive Thai youth aged 14 to 21 years. A questionnaire previously validated in Thailand measured sexual self-efficacy. There were low levels of sexual activity with 13 respondents having sex in the last 6 months. The sexual self-efficacy scales were inversely related to the risk behaviors of having sex, having multiple partners, and drinking alcohol in the last 6 months. The scores of the sexual self-efficacy scale and its subscales were significantly lower in those aged 17 to 21 than in 14 to 16. Sexual risk behaviors were significantly higher in those aged 17 to 21 than in 14 to 16. These findings suggest that interventions to increase sexual self-efficacy should be emphasized as HIV-infected Thai youth reach late adolescence.
This study evaluated how educational attainment impacts clinical outcomes of HIV-positive patients in Durban, South Africa. The authors conducted a prospective study of 466 adult HIV-positive patients initiating antiretroviral therapy (ART) at an urban TB-HIV clinic from October 2004 to June 2007. The level of educational attainment (highest grade completed) was assessed at ART initiation. The authors measured tuberculosis treatment outcomes as well as death, lost to follow-up, viral suppression (HIV RNA <400 copies/mL), and immunologic response (CD4 ≥200 cells/mm3) at 6, 12, and 24 months after ART initiation. After 24 months of ART initiation, there were 43 deaths; viral suppression and immunologic response were observed in 88% and 83% of the remaining patients, respectively. The authors found no association between level of educational attainment and mortality (P = .12), loss to follow-up (P = .85), virologic response (P = .51), or immunologic response (P = .63). Similar findings were observed at 6 and 12 months post-ART initiation.
Emergence of transmitted HIV drug resistance (TDR) is a concern after global scale-up of antiretroviral therapy (ART). World Health Organization had developed threshold survey method for surveillance of TDR in resource-limited countries. ART in Thailand has been scaling up for >10 years. To evaluate the current TDR in Thailand, a cross-sectional study was conducted among antiretroviral-naive HIV-infected patients aged <25 years who newly visited infectious disease clinic in a university hospital, in 2011. HIV genotypic-resistance test was performed. World Health Organization 2009 surveillance drug-resistance mutations were used to define TDR. Of 50 patients, the prevalence of TDR was 4%. Of 2 patients with TDR, 1 had K103N and the other had Y181C mutations. Transmitted HIV drug resistance is emerging in Thailand after a decade of rapid scale-up of ART. Interventions to prevent TDR at the population level are essentially needed in Thailand. Surveillance for TDR in Thailand has to be regularly performed.
The aim of this study was to compare the retention in medical care and antiretroviral (ARV) treatment of individuals living with HIV and AIDS to antiretroviral therapy in southern Brazil according to their "race" or skin color. This study is part of a 225-day prospective trial, comprising 7 interviews, in which an intervention designed to improve adherence to treatment was tested. A convenience sample of 73 individuals living with HIV and/or AIDS enrolled in this follow-up procedure. The mean length of continuance in treatment was 161.5 (standard deviation [SD] = 18.6; 95% confidence interval [CI] = 125-198) and 138.4 (SD = 14.1; 95% C.I. = 111-166) days in the "nonwhite" and "white" categories, respectively. There was no significant difference between the 2 categories, 2(1, n = 72) = 0.76, P = .38, which include similar levels of retention in medical care and treatment with ARV medications between groups of individuals categorized as white and nonwhite in this sample.
With transmission of HIV occurring mainly through heterosexual contact, it is paramount to identify serodiscordant couples and implement preventive strategies that will protect the negative partner. The burden of serodiscordance and its predictors in Ethiopia is not clearly understood due to the dearth of data.
To assess the prevalence and predictors of HIV serodiscordance among couples tested in Jimma University Specialized Hospital (JUSH) Voluntary Counseling and Testing (VCT) center.
The study employed a case–control study design conducted at VCT center of JUSH in all registered serodiscordant couples and seroconcordant couples that were selected from the registered clients in the period from 2003 to 2010. A pretested structured questionnaire was used for data collection using medical chart abstraction. Data were entered, cleaned, and coded using Statistical Package of Social Sciences (SPSS) version 16.
The prevalence of serodiscordance in the study population was found to be 8.4%. Male and female discordants accounted for 5.8% (137) and 2.6% (62), respectively. Rare use of condom (adjusted odds ratio [AOR] = 7.2; 95% confidence interval [CI] = 1.59-32.54) and active tuberculosis (TB) at enrollment (AOR= 17.7; 95% CI = 2.3-139.2) were significantly found to be the predictors of serodiscordance.
The prevalence of serodiscordance in the study area was found to be low, but it contributes to a clinically significant population that mandates implementation of preventive strategy. Sero-positive individuals who use condoms rarely should be encouraged to have their partners tested, and the association between active TB and serodiscordance underscores the need for further study.
The aim of this study was to evaluate to what extent travel-related factors may cause adherence failure to antiretroviral therapy (ART) in otherwise adherent migrants when traveling back to Africa. HIV-infected sub-Saharian migrants living in France with a plasma HIV viral load < 200 copies/mL, with no change in ART for ≥3 months and who were about to visit their native country for between 2 weeks and 6 months were enrolled for the study. Patients completed a self-administered adherence questionnaire both at enrollment and during the week following their return to France. Adherence failure occurred in 23 (11.5%) of 200 patients. Negative perception about ART effectiveness (adjusted odds ratio = 4.3; 95% confidence interval = 1.3-13.7), unexpected traumatic events during their stay in their native country (7.8; 2.3-26.1), and a prolongation of their stay (5.2; 1.4-20.4) were independently associated with a higher likelihood of adherence failure. Owning/renting one’s house in France (0.30; 0.10-0.96), singlehood (0.23; 0.05-1.00), and HIV status disclosure (0.19; 0.05-0.76) were correlates of sustained adherence during traveling.
Untreated psychiatric illness is detrimental to the health and well-being of HIV-infected youth. This study examines the relationships between social and demographic variables and the rates of psychiatric treatment among HIV-infected youth.
Analyses are from a cross-sectional survey of 1706 HIV-infected youth (13-26 years) in care at treatment sites or affiliates of the Adolescent Medicine Trials Network for HIV/AIDS Interventions from 2010 to 2011. Among the youth who reported recent significant mental health symptoms, comparisons on demographic variables (including race, ethnicity, language spoken, level of education, sexual orientation, and household income) were made.
Psychiatrically symptomatic black youth were significantly less likely than symptomatic nonblack peers to receive mental health care (37.4% versus 48.6%) and psychiatric medications (19.3% versus 26.9%).
Care providers should be alerted to the potential disparities in mental health care treatment that exist for black youth living with HIV.
The use of raltegravir (RAL) is not preferred to prevent perinatal transmission in pregnancy due to lack of safety and pharmacokinetic data in this population. Data have been limited to few case reports of patients who present for treatment late in pregnancy, have multidrug resistance, or have poor adherence, requiring an additional class such as an integrase inhibitor to further lower viral load. This case report describes and supports the initiation of RAL in very late pregnancy (week 33) to rapidly decrease viral load and successfully prevent perinatal transmission. By increasing the efficacy and safety data of RAL use in pregnancy, we believe this report can help provide some guidance on the management of complex cases.
Studies have shown immunological and morphological alterations in the esophagus during the course of AIDS. Esophageal postmortem samples of 22 men with AIDS autopsied in a teaching hospital between 1982 and 2009 were collected. We carried out revision of the autopsy reports and medical records, morphometric analysis (Image J and KS-300 Kontron-Zeiss), and immunohistochemical (anti-S100, anti-IgA, anti-IgG, and anti-IgM) analysis of the esophagus. In accordance with most of the parameters evaluated, age and the smoking habit harmed the esophageal local immunity, whereas the use of antiretroviral therapy improved the immune characteristics of this organ. Patients with esophagitis also presented immunological fragility of the esophagus. This leads to the conclusion that alterations in the esophageal epithelium of patients with AIDS are not only caused by direct action of HIV but also the clinical and behavioral characteristics of the patient.
Primary caregivers of HIV/AIDS patients face enormous burden, which if inappropriately coped, leads to psychiatric morbidity. Little is known of what role caregiver’s age and gender play in this.
To assess the socio-demographic profile and the influence of age and gender on coping strategies and psychiatric morbidity.
Sixty caregivers were assessed on a semistructured sociodemographic proforma, a coping checklist, and the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV; [SCID-I]).
Majority of the carers were young, equally from both genders, and used the same number of coping strategies which increased with age. "Avoidance" was preferred by males and older carers. Youngsters had maximum psychiatric morbidity, majority of the depressed were females, while 90% of nicotine dependants were males.
Gender, but not age, decided the style of coping and extent of psychiatric morbidity hence gender-specific interventions will improve the quality of life of the carers and their wards.
Factors associated with initial methicillin-resistant Staphylococcus aureus (MRSA) skin and soft-tissue infections (SSTIs) and their recurrence have not been fully elucidated among HIV-infected persons.
We retrospectively evaluated a large cohort of HIV-infected patients from 1993 to 2010 for culture-proven MRSA SSTIs. Separate logistic regression models evaluated factors associated with initial and recurrent infections.
Of the 794 patients, 63 (8%) developed an initial infection (19.8 infections/1000 person years [PY]); risk factors included CD4 count <500 cells/mm3 and HIV RNA level ≥400 copies/mL (P < .01), US Centers for Disease Control and Prevention (CDC) stage C versus A/B (P < .01), and injection drug use (IDU, P < .01). In all, 27% developed recurrence (206 infections/1000 PY); risk factors included hospital admission (P = .02). Minocycline for treatment of the initial infection was associated with an 80% decreased odds for recurrence (P = .03).
HIV control and avoidance of IDU may be useful in reducing rates of MRSA SSTIs among HIV-infected persons.
This study was based on an analysis of an existing database compiled from 475 medical records of people living with HIV/AIDS admitted to an acute-care hospital in New York City in 2004. The characteristics of patients with HIV infection that received physical therapy were determined. Differences between patients with HIV infection that did and did not receive physical therapy, as well as predictors of receipt of physical therapy, were identified. The physical therapy subgroup (n = 69) had a mean age of 48.3 years, consisted of more men than women, and was predominately black, with public health insurance. Admissions were commonly due to non-AIDS-defining illness as the primary diagnoses, accompanied by several comorbidities. Admissions often presented with functional deficits, incurred a prolonged length of stay, and required assistance at discharge. Differences existed between the physical therapy subgroup and the non-physical therapy subgroup (n = 406). Predictors of receipt of physical therapy were functional status on admission and length of stay.
The continuing paucity of effective interventions to reduce HIV/AIDS stigma is troubling, given that stigma has long been recognized as a significant barrier to HIV prevention, treatment, care, and support. Ineffectual HIV/AIDS stigma-reduction interventions are the product of inadequate conceptual frameworks and methodological tools. And while there is a paucity of effective interventions to reduce stigma, there is no shortage of conceptual frameworks intending to offer a comprehensive understanding of stigma, ranging from sociocognitive models at the individual level to structural models at the macrolevel. Observations highlighting inadequacies in the individualistic and structural models are offered, followed by the theory of structuration as a possible complementary conceptual base for designing HIV/AIDS stigma-reduction interventions.
There is a dire need for interventions that will address the multiple factors—poverty, substance use, early sexual debut, and violence—that influence Haitian youth’s engagement in risky behaviors. The deteriorating socioeconomic and political state of the country has had a deleterious effect on the sociocultural milieu and on the boundaries that have heretofore kept risky behaviors in check. Historically, the lakou system, a community-based approach that supports the family unit, has disintegrated, leading to the disruption of traditional parenting patterns. The unstable economic system has also led to the increasing use of children from poor families, who through the restavek system, are sent to work as servants in other households. The breakdown of traditional systems, coupled with the increasing economic and political instability, has had a significant effect on Haitian adolescents. Among boys, increased levels of substance use have been associated with multiple sex partnerships and very early sexual debut. Among girls, extremely high rates of sexual abuse and forced sex have led to relatively high levels of HIV. While the majority of them have been exposed to behavior change messages, behavior change itself has lagged because many adolescents do not accurately perceive their risk exposure. This review explores the risks of HIV transmission among Haitian youth, with a focus on vulnerability factors, including substance use, culture, and the socioeconomic context, and provides recommendations for intervention. An ecosystemic approach, designed specifically for Haitian youth and that takes environmental context and culture into account, is needed.
Introduction: Stigmatization and discrimination impact negatively on interventions and act as barriers to all HIV/AIDS activities. This study assessed the relationship between stigmatization and discrimination and adherence to antiretroviral therapy (ART) among HIV-infected patients attending the Federal Medical Centre, Ido-Ekiti, Nigeria. Methods: A cross-sectional study was carried out among respondents selected by systematic random sampling. Structured, interviewer-administered questionnaires were used to collect data subsequently analyzed with SPSS 16. Results: A total of 100 respondents comprising 61 (61.0%) female participants were interviewed. A large proportion, 92.0%, had a low level of stigmatization. In all, 88 (88.0%) had a good level of antiretroviral adherence using a threshold of <underline>></underline>95%. More people living with HIV/AIDS (PLWHAs) with low stigmatization and discrimination had good adherence to ART (P < .001). Conclusion: The PLWHAs with low levels of stigmatization and discrimination are more likely to adhere to ART than those with high levels. Counseling services and health education on adherence should be a strong component of all PLWHA care.
Objectives: To compare quantiferon-TB gold "in tube" (QFT-IT) with the conventional tuberculin skin test (TST) for the diagnosis of latent tuberculosis infection (LTBI) in HIV-infected adults in a setting highly endemic for tuberculosis with BCG vaccinated population in Bangalore, Karnataka, India. Patients and Methods: The study population (100 BCG-vaccinated adults) was divided into 4 groups: HIV patients with TB patient contact, HIV patients with past history of TB, TB patients (positive control), and healthy volunteers (negative control). Results: Overall agreement between TST and QFT-IT was 52.4% ( = 0.22). Increasing the TST cutoff value from 5 mm to 10 mm among HIV-positive groups resulted in better agreement 62.5% in Group 1 and 81.2% in Group 2. Discussion: In a setting with high TB prevalence, the TST gives increased false positives in HIV-positive groups if 5 mm is used as the cutoff value. This could be minimized by increasing the cutoff to 10 mm. Conclusion: The 2-step approach (initial testing of all cases with TST and confirmation of only those positive in TST by testing with QFT-IT) will be economical and help in treating LTBI cases in lower middle income countries like India.
Background: In sub-Saharan countries, HIV testing and treatment facilities are available, especially at subsidized rates for the past few years. Methods: A prospective and descriptive review was conducted at Yalgado Ouédraogo Teaching Hospital Internal Medicine department in Ouagadougou, using personal case report forms, between June 2009 and August 2010 in all newly diagnosed adults with positive HIV antibody. Results: The study participants consisted of 191 patients at a median age of 37 years (range, 18-65 years) and sex ratio (men/women): 0.66. In all, 110 (57.6%) patients were symptomatic. Fourteen patients were lost to follow-up. Of the 177 patients, 144 had CD4 count <350 cells/mm3 and all have been treated. At the ninth month, weight gain and immune restoration were significant (P < .01); only 79 of the 144 patients had viral load measurement, and 76 of the 79 were undetectable. Mortality rate of treated patients was 6.25%. Conclusion: Laboratory tests and highly active antiretroviral therapy make the management of patients easier, but a majority of them still presented late and were still lost to follow-up. Nevertheless, we have excellent treatment success.
Depression is common among people living with HIV/AIDS in sub-Saharan Africa. Yet, little is known about how depression influences physical health and socioeconomic well-being in the context of antiretroviral therapy (ART). Semistructured interviews with 40 adult HIV clients receiving ART in Uganda were conducted to assess experiences prior to and after HIV diagnosis and initiation of ART. Content analysis revealed themes that were suggestive of the following patterns: (1) functioning decreased after patients were diagnosed with HIV, but improved following ART, (2) depression is associated with lower physical health functioning and work status levels after both HIV diagnosis and ART, and (3) antidepressant medication is associated with better functioning compared with patients with depression not receiving depression treatment. These findings suggest that depression plays a role in the deleterious effects of HIV on functioning, and that antidepressant treatment provided alongside ART may serve to help individuals regain functioning, particularly employment. These findings highlight the potential value of integrating depression treatment into HIV care.
HIV/AIDS stigma continues to be a challenge for HIV prevention and treatment. When health professionals manifest stigma it can limit access to quality treatment. With an ever-growing epidemic among Latinos, including Puerto Ricans living on the Caribbean Island, the social and structural factors that foster HIV/AIDS stigma need to be understood. In this study, we documented the association of religion with HIV/AIDS stigma in a sample of medical students in Puerto Rico. Findings suggest that importance placed on religion, and participation in religious activities, is associated with HIV/AIDS stigma for this population.
Realization of the right to health occurs along a continuum including national ratification of international treaties such as the Convention on the Rights of the Child, passage of domestic laws and policies that may specify modes of implementation and enforcement such as Kenya’s Constitution and HIV and AIDS Prevention and Control Act, and actual implementation of domestic laws and policies such as through the regulation and delivery of health services. The stages heuristic theoretical framework describes the public policy continuum as consisting of marked stages: agenda setting, policy formulation, policy implementation, and evaluation. This case study illustrates the continuum in Kenya with regard to pediatric HIV testing. Kenya has made progress applying law, policy, and science to reduce vertical transmission of HIV and increase HIV testing of infants, although several challenges remain. Progress in policy implementation may reduce mother-to-child transmission and increase pediatric HIV testing.
Background: CD4 counts vary in different populations. The present study was conducted to determine CD4 counts in different World Health Organization (WHO) clinical stages in antiretroviral therapy naïve individuals and to find out optimum CD4 cutoffs. Method: Data of adult HIV seropositive patients who underwent CD4 count and total lymphocyte count (TLC) testing were included for analysis. The severity of immunosuppression was graded based on WHO criteria. To establish optimum CD4 cutoff values, receiver–operator characteristics (ROC) curves were generated. Results: Of 754 patients, 52.2% had CD4 counts <200 cells/mm3, but only 2.3% belonged to WHO stage IV. Newer CD4 cutoffs generated were 280, 120-280, <120 cells/mm3. Spearman rank correlation between CD4 counts and TLC was found to be weak (r = .32). Conclusion: The cutoff values of CD4 counts for HIV disease may need to be revised for India. Regular CD4 count estimation is a must for monitoring disease progression in people living with HIV/AIDS.
Individuals testing HIV positive were interviewed at testing centers, followed prospectively and interviewed again when they registered at referral antiretroviral therapy (ART) centers (ARTCs). Those who did not register at ARTCs were traced and interviewed in the community. A total of 1057 newly diagnosed people living with HIV (PLHIV; 52% women; mean age, 34.7 years) were recruited. A total of 73.5% of PLHIV registered at referral ARTCs within 60 days, 17.9% did not register and were interviewed in the community, and 8.6% were not interviewed. The 2 main reasons cited for not registering were a perception of good health (30%) and work/family engagements (22%). Single clients (adjusted relative risk [ARR]: 1.54; 95% confidence interval [CI]: 1.02-2.34), participants who had not disclosed their HIV status (ARR: 2.32; 95%CI: 1.77-3.05), participants who knew a PLHIV (ARR: 1.89; 95% CI: 1.41-2.53), and participants from laborer households (ARR: 2.66; 95%CI:1.15-6.15) were more likely to not register. In conclusion, the majority of newly diagnosed PLHIV do reach ARTCs. Disclosure concerns and a perception of good health prevent PLHIV from accessing services.
HIV/AIDS-related stigma has been linked to poor adherence resulting in drug resistance and the failure to control HIV. This study used both quantitative and qualitative methods to examine stigma and its relationship to adherence in 30 HIV-infected Thai youth aged 14 to 21 years. Stigma was measured using the HIV stigma scale and its 4 subscales, and adherence was measured using a visual analog scale. Stigma and adherence were also examined by in-depth interviews. The interviews were to determine whether verbal responses would match the scale’s results. The mean score of stigma perception from the overall scale and its 4 subscales ranged from 2.14 to 2.45 on a scale of 1 to 4, indicating moderate levels of stigma. The mean adherence score was .74. The stigma scale and its subscales did not correlate with the adherence. Totally, 17 of the respondents were interviewed. Contrary to the quantitative results, the interviewees reported that the stigma led to poor adherence because the fear of disclosure often caused them to miss medication doses. The differences between the quantitative and the qualitative results highlight the importance of validating psychometric scales when they are translated and used in other cultures.
Health system responsiveness (HSR), a measure of patient health care experience, may influence adherence to HIV/AIDS care and be an important predictor of outcomes. We studied the relationship between HSR, patient factors, and visit nonadherence in 16 President's Emergency Plan for AIDS Relief–supported HIV/AIDS clinics in Dar es Salaam. An HSR survey was administered in 2009, and all clinic visits 1 year following the interviews were analyzed for 720 patients on antiretrovirals (ARVs). Definitions of visit nonadherence were (1) low visit constancy ([VC], no visit in <underline>≥</underline>1 quarter), (2) gaps in care (>60 days between visits), (3) no visit in last quarter (VLQ). The relationships between factors were analyzed using multivariate analysis with adjusted odds ratio (AOR) and 95% confidence intervals (CI) reported. Few patients were nonadherent using VLQ (14%) and VC (28%). Gaps in care were more common (49.6%) and associated with younger age (AOR: 3.86 [2.02-7.40]), no explanation of side effects (AOR: 2.21 [1.49-3.28]), and shorter antiretroviral therapy (ART) duration (0-3 months AOR: 1.49 [1.09-2.03]; 3-6 months AOR: 2.44 [1.40-4.25]). No VLQ was associated with younger age (AOR: 3.40 [1.63-7.07]), poor health care worker (HCW) communication (AOR: 4.83 [1.39-16.78]), and less time on ART (0-3 months AOR: 5.04 [2.47-10.30]; 3-6 months AOR: 3.09 [1.72-5.57]). Younger age, poor HCW communication, and shorter ART duration also predicted lower VC, as did higher patient-HCW ratios. The rates of visit nonadherence differed based on the definitions used. Younger age, shorter time on ART, and poor HCW communication predicted lower adherence regardless of the definition. More work is needed to understand the relationship between HSR, patient factors, and different patterns of visit nonadherence and their impact on ART outcomes.
Background: Depression is emerging as a highly prevalent psychiatric condition among people living with HIV/AIDS (PLWHA). Perceived family support (PFS) buffers depression among chronic disease patients. However, a similar relationship among PLWHA is unexplored. Objective: To examine the relationship between PFS and depression among PLWHA in the Kathmandu Valley, Nepal. Methods: In this cross-sectional study, depression was measured by Beck Depression Inventory Ia. Perceived family support was measured by Nepali Family Support and Difficulties Scale. The status of depression was compared between 208 PLWHA and 208 HIV-negative participants. The relationship between PFS and depression was examined only among PLWHA. Results: Among each of the 208 participants, the number of depressed PLWHA (n = 61,29.3%) was higher than that of HIV-negative participants (n = 13,6.2%; P < .001). Perceived family support had a negative association with depression in PLWHA (adjusted odds ratio [AOR] = 0.20, 95% confidence interval [CI] = 0.08-0.53). Conclusion: In Nepal, PLWHA display a higher level of depression than HIV-negative people, and a lower level of PFS is associated with depression among PLWHA. Improved family support might be helpful in reducing depression among Nepalese PLWHA.
Background: The clinical presentation of cardiac abnormalities in HIV-infected patients may be atypical or masked by concurrent illnesses that lead to misdiagnosis or they remain undiagnosed; therefore, this study was aimed to determine the frequency of cardiac abnormalities in HIV-infected patients. Material and Methods: Consecutive HIV-infected patients of age >13 years were studied for 3 months, after obtaining their consent. After clinical assessment, chest x-ray, electrocardiogram, 2-dimensional echocardiography and serum Troponin T levels were done. Results: A total of 100 patients were studied, cardiomegaly was observed in the x-ray of 15% of them, abnormal electrocardiogram was seen in 18%, 2-dimensional echocardiography was abnormal in 67%; and diastolic dysfunction (42.8%) was the commonest abnormality followed by dilated cardiomyopathy (17.6%). Serum troponin T was elevated in 8%. The variables, opportunistic infections (OIs), antiretroviral therapy (ART), stage of HIV disease, and CD4 counts, did not affect the frequency of diastolic dysfunction. Conclusion: The diastolic dysfunction is the most common cardiac abnormality observed in HIV-infected patients.
Background: HIV medication nonadherence is a major problem, yet many providers lack the time and training to carefully ask patients about their adherence. Objective: To design and pilot a technology-assisted intervention, for use in clinical settings, to identify nonadherent patients. Methods: The intervention uses audio computer-assisted self-interview (ACASI) to improve the assessment of adherence and medication-related problems. Patients completed a touch screen computer ACASI which generated graphic clinician and patient reports for discussion during the clinical encounter. Results: 72 patients and 11 providers participated in this study. The patients easily completed the ACASI. Adherence was 63% (3-day) and 47% (30-day). Using the ACASI, 22% of patients identified themselves as nonadherent, when their providers perceived them as adherent. Conclusions: This ACASI-based intervention is easy to use and helps identify nonadherence. The pilot test engendered enhancements including the addition of phone-based adherence counseling. A larger trial is underway to evaluate whether the intervention leads to improved HIV-related outcomes.
Background: This pilot study evaluated an intervention designed to enhance adherence among those new to antiretroviral therapy. Methods: Participants (n = 80) were recruited from a hospital clinic in Chandigarh, India, and randomized to a 3-month group intervention or individual enhanced standard of care followed by crossover of condition and assessed over 6 months. Adherence was measured by prescription refill, pill count, and self-report. Results: At baseline, 56% of group condition (immediate intervention) and 54% of individual condition (delayed intervention) participants were nonadherent by pill count and 23% of group and 26% of individual condition participants self-reported skipping medication at least once over the last 3 months. From the postintervention to long-term follow-up, adherence in the group condition (immediate intervention) improved in comparison with adherence in the individual condition (delayed intervention; 2 = 5.67, P = .02). Conclusions: Results support the use of interventions early in treatment to provide information and social support to establish long-term healthy adherence behaviors.
The purpose of this descriptive study is to highlight the physical and mental health symptoms of 68 rural women living with AIDS (WLA) in India, their compliance to antiretroviral therapy (ART) medication, and barriers to accessing health care within the past 6 months. Physical and mental health status was obtained by self-report, administered by questionnaire and physician-determined clinical assessment, as well as selected objective parameters. Findings revealed that while rural WLA had been on antiretroviral therapy for just under 2 years, they self-reported a high prevalence of physical symptoms, and more than half reported high levels of depressive symptoms and major barriers to accessing health care. CD4 levels, body weight, and basal metabolic rate were also low. While the rural and urban WLA faced similar health care challenges, the demographic characteristics of the rural women may make them more vulnerable, as they are less adherent to ART and slimmer than their urban counterparts.
The Caribbean and Central America represent a formidable challenge for researchers and policy makers in the HIV field, due to their pronounced heterogeneity in terms of social, economic, and cultural contexts and the different courses the HIV epidemic has followed in the region. Such contrasting contexts and epidemics can be exemplified by 2 countries that share the island of Hispaniola, the French Creole-speaking Haiti, and the Spanish-speaking Dominican Republic. Haiti has experienced the worst epidemics outside of sub-Saharan Africa. Following a protracted economic and social crisis, recently aggravated by a devastating earthquake, the local HIV epidemic could experience resurgence. The region, strategically located on the way between coca-producing countries and the profitable North American markets, has been a transshipment area for years. Notwithstanding, the impact of such routes on local drug scenes has been very heterogeneous and dynamic, depending on a combination of local mores, drug enforcement activities, and the broad social and political context. Injecting drug use remains rare in the region, but local drug scenes are dynamic under the influence of increasing mobility of people and goods to and from North and South America, growing tourism and commerce, and prostitution. The multiple impacts of the recent economic and social crisis, as well as the influence of drug-trafficking routes across the Caribbean and other Latin American countries require a sustained effort to track changes in the HIV risk environment to inform sound drug policies and initiatives to minimize drug-related harms in the region.