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Objective We examined whether having a psychiatric disorder among HIV-infected individuals is associated with differential rates of discontinuation of HAART and whether the number of mental health visits impact these rates. Design This longitudinal study (fiscal year: 2000-2005) used discrete time survival analysis to evaluate time to discontinuation of HAART. The predictor variable was presence of a psychiatric diagnosis (serious mental illness versus depressive disorders versus none). Setting Five United States outpatient HIV sites affiliated with the HIV Research Network. Patients The sample consisted of 4989 patients. The majority was nonwhite (74.0%) and men (71.3%); 24.8% were diagnosed with a depressive disorder, and 9% were diagnosed with serious mental illness. Main outcome measures Time to discontinuation of HAART adjusting for demographic factors, injection drug use history, and nadir CD4 cell count. Results Relative to those with no psychiatric disorders, the hazard probability for discontinuation of HAART was significantly lower in the first and second years among those with SMI [adjusted odds ratio: first year, 0.57 (0.47-0.69); second year, 0.68 (0.52-0.89)] and in the first year among those with depressive disorders [adjusted odds ratio: first year, 0.61 (0.54-0.69)]. The hazard probabilities did not significantly differ among diagnostic groups in subsequent years. Among those with psychiatric diagnoses, those with six or more mental health visits in a year were significantly less likely to discontinue HAART compared with patients with no mental health visits. Conclusion Individuals with psychiatric disorders were significantly less likely to discontinue HAART in the first and second years of treatment. Mental health visits are associated with decreased risk of discontinuing HAART.

Increased longevity as a result of HAART raises new questions about the best treatment The median age of people living with HIV in the developed world is increasing because of improved longevity from highly active antiretroviral therapy (HAART) and an increase in new HIV infections in older people.1 The prevalence of HIV in older people will continue to increase over the next decade, and around 50% of people living with HIV will be older than 50 by 2015.2 Although 50 years is not a common threshold for advanced age, early in the HIV epidemic the Centres for Disease Control and Infection identified HIV infected patients aged 50 or more as a separate group because the mean age of infected people was then much lower than 50. In the early days of the HIV epidemic older patients had higher morbidity, higher mortality, and a shorter AIDS free survival than younger people with HIV. …

Mental illness (MI) and illicit drug use (DU) frequently co-occur. We sought to determine the individual and combined effects of MI and DU on highly active antiretroviral therapy (HAART) receipt and HIV-RNA suppression among individuals engaged in HIV care. Using 2004 data from the HIV Research Network (HIVRN), we performed a cross-sectional study of HIV-infected patients followed at seven primary care sites. Outcomes of interest were HAART receipt and virological suppression, defined as an HIV-RNA

The prevalence of HIV in patients over the age of 50 years is increasing. Although older patients may achieve equal or better virologic suppression at equal rates compared with younger patients, the immunologic benefit of highly active antiretroviral therapy (HAART) in older patients may be reduced compared with younger patients. Comorbidities are more common in older patients than younger patients and can impact management of HIV in these patients. Providers must be cognizant of drug-drug interactions and side effects of HAART regimens when selecting an antiretroviral regimen in older HIV patients. As the HIV-infected population ages, there is a growing need to better determine the ideal HAART regimen and timing of HAART initiation in older patients.

The decision to perform lumbar puncture in patients with asymptomatic human immunodeficiency virus (HIV) infection and syphilis is controversial. The Centers for Disease Control and Prevention recommend certain criteria that warrant lumbar puncture. Here, we assess the performance of these criteria for detecting asymptomatic neurosyphilis (ANS).Eligible subjects consisted of all patients with concurrent HIV infection and syphilis in a prospective clinical cohort who had no neurologic symptoms at the time of lumbar puncture. We retrospectively applied different stratification criteria to calculate the performance of lumbar puncture in detecting ANS: (1) lumbar puncture in patients with late latent syphilis or syphilis of an unknown duration, regardless of the CD4 cell count or rapid plasma reagin titer; (2) lumbar puncture if the CD4 cell count was 350 cells/mL and/or the rapid plasma reagin titer was 1:32, regardless of the syphilis stage; and (3) lumbar puncture in the context of serologic nonresponse to syphilis therapy.Two hundred two of 231 patients with syphilis did not have neurologic symptoms. Immediate lumbar puncture was performed for 46 patients, and 10 cases (22%) of ANS were detected. With use of the first criterion, 2 (14%) of 10 cases of ANS in patients with early-stage syphilis would have been missed (sensitivity, 80% [95% confidence interval [CI], 44%-97%]; specificity, 23% (95% confidence interval [CI], 11.4%-40.2%) [corrected] Criterion 2 would not have missed any cases of ANS (sensitivity, 100% [95% CI, 70%-100%]; specificity, 13.2% (95% CI, 4.4%-29.1%) [corrected] but would have required that a lumbar puncture be performed for 88% of patients. Performance of lumbar puncture performed in 13 cases based on serologic nonresponse to syphilis therapy yielded 4 cases (31%) of ANS.In patients with concurrent HIV infection and syphilis, the use of criteria based on rapid plasma reagin titer and CD4 cell count, instead of stage-based criteria, improved the ability to identify ANS.

BACKGROUND The optimal time for the initiation of antiretroviral therapy for asymptomatic patients with human immunodeficiency virus (HIV) infection is uncertain. METHODS We conducted two parallel analyses involving a total of 17,517 asymptomatic patients with HIV infection in the United States and Canada who received medical care during the period from 1996 through 2005. None of the patients had undergone previous antiretroviral therapy. In each group, we stratified the patients according to the CD4+ count (351 to 500 cells per cubic millimeter or >500 cells per cubic millimeter) at the initiation of antiretroviral therapy. In each group, we compared the relative risk of death for patients who initiated therapy when the CD4+ count was above each of the two thresholds of interest (early-therapy group) with that of patients who deferred therapy until the CD4+ count fell below these thresholds (deferred-therapy group). RESULTS In the first analysis, which involved 8362 patients, 2084 (25%) initiated therapy at a CD4+ count of 351 to 500 cells per cubic millimeter, and 6278 (75%) deferred therapy. After adjustment for calendar year, cohort of patients, and demographic and clinical characteristics, among patients in the deferred-therapy group there was an increase in the risk of death of 69%, as compared with that in the early-therapy group (relative risk in the deferred-therapy group, 1.69; 95% confidence interval [CI], 1.26 to 2.26; P

Objective Although co-occurring psychiatric disorders are highly prevalent among those with HIV, little is known about the use of outpatient mental health services (MHS) and psychotropic medication in the highly active antiretroviral therapy (HAART) era. Methods During 2003, 951 patients were interviewed at 14 sites in the HIV Research Network. Patients were questioned about use of MHS and psychotropic medications. Logistic regression was used to identify socio-demographic and clinical factors associated with MHS and psychotropic medication utilization. Results The sample characteristics were as follows: 68% male, 52% black, 14% Hispanic, median age 46 years (range 20–85), 69% were on HAART. Approximately 34% reported at least one MHS within 6 months and 37% reported use of psychotropic medication for a mental health condition. In multivariate logistic regression, MHS was greater among disabled patients [adjusted odds ratio 2.39 (95% CI 1.53–3.72)], current [2.26 (1.53–3.35)] and former drug users [1.84 (1.24–2.73)], and those with more than seven primary care visits in the past 6 months. Blacks [0.61 (0.41–0.92)] were significantly less likely to use MHS compared to whites. Similarly, usage of psychotropic medications was greater among disabled patients [1.79 (1.14–2.82)], women [1.66 (1.13–2.43)], )] and those with more than seven primary care visits. Blacks [0.37 (0.24–0.58])] and Hispanics [0.39 (0.22–0.72)] were less likely to use a psychotropic medication. HAART utilization was not associated with MHS or psychiatric medication use. Conclusions In the HAART era, self-reported rates of mental health service and psychotropic medication utilization are high. Blacks continue to report lower use of MHS and psychotropic medication compared to whites.

As the HIV epidemic has evolved to become a chronic, treatable condition the focus of HIV care has shifted from the inpatient to the outpatient arena. The optimal structure of HIV care in the outpatient setting is unknown. Using the HIV Research Network (HIVRN), a federally sponsored consortium of 21 sites that provide care to HIV-infected individuals, this study attempted to: (1) document key features of the organization of care in HIVRN adult clinics and (2) estimate variability among clinics in these parameters. A cross-sectional survey of adult clinic directors regarding patient volume, follow-up care, provider characteristics, acute patient care issues, wait times, patient safety procedures, and prophylaxis practices was conducted from July to December 2007. All 15 adult HIVRN clinic sites responded: 9 academic and 6 community-based. The results demonstrate variability in key practice parameters. Median (range) of selected practice characteristics were: (1) annual patient panel size, 1300 (355–5600); (2) appointment no-show rate, 28% (8%–40%); (3) annual loss to follow-up, 15% (5%–25%); (4) wait time for new appointments, 5 days (0.5–22.5), and follow-up appointment, 8 days (0–30). The majority of clinics had an internal mechanism to handle acute patient care issues and provide a number of onsite consultative services. Nurse practitioners and physician assistants were highly utilized. These data will facilitate improvements in chronic care management of persons living with HIV.

HIV infection and substance use disorders are chronic diseases with complex contributions to health-related quality of life (HRQOL). We conducted a cross-sectional survey of 951 HIV-infected adults receiving care at 14 HIV Research Network sites in 2003 to estimate associations between HRQOL and specific substance use among HIV-infected patients. HRQOL was assessed by multi-item measures of physical and role functioning, general health, pain, energy, positive affect, anxiety, and depression. Mental and physical summary scales were developed by factor analysis. We used linear regression to estimate adjusted associations between HRQOL and current illicit use of marijuana, analgesics, heroin, amphetamines, cocaine, sedatives, inhalants, hazardous/binge alcohol, and drug use severity. Current illicit drug use was reported by 37% of subjects. Mental HRQOL was reduced for current users [adjusted beta coefficient -9.66, 95% confidence interval [(CI]) -13.4, -5.94] but not former users compared with never users. Amphetamines and sedatives were associated with large decreases in mental (amphetamines: beta = -22.8 [95% CI -33.5, -12.0], sedatives: beta = -18.6 [95% CI -26.2, -11.0]), and physical HRQOL (amphetamines: beta = -11.5 [95% CI -22.6, -0.43], sedatives: beta = -13.2 [95% CI -21.0, -5.36]). All illicit drugs were associated with decreased mental HRQOL: marijuana (beta = -7.72 [95% CI -12.0, -3.48]), non-prescription analgesics (beta = -13.4 [95% CI -20.8, -6.07]), cocaine (beta = -10.5 [95% CI -16.4, -4.67]), and inhalants (beta = -14.0 [95% CI -24.1, -3.83]). Facilitating sobriety for patients with attention to specific illicit drugs represents an important avenue for elevating HRQOL in patients living with HIV.

The rate of comorbidities not related to human immunodeficiency virus (HIV) infection or acquired immunodeficiency syndrome (AIDS) among HIV-infected patients may be higher than expected. We assessed the incidence of comorbidities not related to HIV infection or AIDS by CD4 cell count and highly active antiretroviral therapy (HAART) use status in an HIV clinical practice. A total of 2824 patients contributed 9172 person-years of longitudinal data during the period 1997‐2006. Among patients with a CD4 cell count !350 cells/mm 3 , receipt of HAART was associated with a significantly decreased incidence of comorbidities not related to HIV infection or AIDS. Recent research has suggested that the rate of comorbidities not related to HIV infection or AIDS among HIV-infected patients may be higher than expected. This concern was raised particularly by results from the Strategies for Management of Antiretroviral Therapy Study, a clinical trial of continuous versus interrupted combination antiretroviral therapy [1]. In addition, other researchers have found increased rates of hepatic, cardiovascular, metabolic and/or endocrine, renal, neurologic, and pulmonary events and non–AIDS-defining malignancy among HIV-infected patients [2–7]. If the risk of many of these comorbidities is increased because of HIV infection or advancing immunosuppression, early HAART use may prevent the occurrence of these comorbidities. This analysis assessed the incidence of comorbidities not related

Objectives To define the incidence and risk factors for methicillin resistant Staphylococcus aureus (MRSA) bacteraemia in an HIV-infected population. Methods From January 1, 2000 to December 31, 2004, we conducted a retrospective cohort study. We identified all cases of Staphylococcus aureus bacteraemia (SAB), including MRSA, among patients enrolled in the Johns Hopkins Hospital out-patient HIV clinic. A conditional logistic regression model was used to identify risk factors for MRSA bacteraemia compared with methicillin-sensitive SAB and no bacteraemia in unmatched (1:1) and matched (1:4) nested case-control analyses, respectively. Results Of 4607 patients followed for a total of 11 020 person-years (PY) of follow-up, 216 episodes of SAB occurred (incidence: 19.6 cases per 1000 PY), including 94 cases (43.5%) which were methicillin-resistant. The incidence of MRSA bacteraemia increased from 5.3 per 1000 PY in 2000–2001 to 11.9 per 1000 PY in 2003–2004 (P=0.001). Multivariate analysis demonstrated that independent predictors of MRSA bacteraemia (vs. no bacteraemia) were injection drug use (IDU), end-stage renal disease (ESRD) and CD4 count

Background: Retrospective cohort studies of HIV-infected patients suggest an incidence of venous thromboembolism (VTE) of 1% to 2%, which is 10 times that expected among people without HIV We investigated the prevalence of established risk factors for VTE in this population and explored novel risk factors. Methods: We conducted a case-control study using patients in the Johns Hopkins University AIDS Service cohort. We used conditional logistic regression and paired t tests to test for covariates significantly associated with VTE. Results: We identified 160 patients with VTE diagnosed radiologically or with a clinical course consistent with VTE; 23% of the cases of VTE were diagnosed in hospitalized patients. The incidence of VTE was approximately 0.5% per patient-year. Patients with VTE and control patients did not differ by gender, but black patients were overrepresented among those with VTE (odds ratio [OR] = 1.9, 95% confidence interval [CI]: 1.11 to 3.08) and patients with VTE were older than controls (mean: 39 vs. 37 years; P = 0.001). Patients with VTE had lower CD4 counts (229 vs. 362 cells/mm 3 ; P < 0.0001), higher HIV RNA titers (120,254 vs. 71,262 copies/mL; P= 0.013), and lower hemoglobin concentrations (11.4 vs. 12.7 g/dL; P < 0.0001) preceding the event than those without VTE. The use of highly active antiretroviral therapy was not associated with VTE. In multivariate analyses, independent risks for VTE were age, hospitalization in the past 3 months (OR = 13, 95% CI: 6.4 to 27), central venous catheter use in the past 3 months (OR = 6.0, 95% CI: 2.3 to 16), and a CD4 count

Syphilis and human immunodeficiency virus (HIV) frequently coexist in patients, but the effects of immunosuppression on the course of syphilis are unknown. Our goal was to determine whether the degree of HIV-mediated immunosuppression and the use of highly active antiretroviral therapy impact syphilis serologic responses.We assessed all cases of syphilis with positive serologic test results from 1990 through 2006 in a prospective, observational clinical cohort of HIV-infected patients. We defined seroreversion as the loss of reactivity in a patient who previously had a serologic test result positive for syphilis. We defined serologic failure as the lack of a 4-fold decrease in rapid plasma reagin titers 270-365 days after therapy or a 4-fold increase in titersor =30 days after therapy. We used Cox proportional hazards models with statistical adjustments for multiple failure instances.One hundred eighty subjects experienced 231 cases of syphilis. The median follow-up time was 5.3 years. A total of 71 episodes of serologic failure were documented. A CD4 cell count of200 cells/mL at the time of syphilis diagnosis was associated with an increased risk of serologic failure (adjusted hazard ratio, 2.48; 95% confidence interval, 1.26-4.88). The receipt of highly active antiretroviral therapy was associated with a 60% reduction in the rate of serologic failure (adjusted hazard ratio, 0.40; 95% confidence interval, 0.21-0.75), independent of concomitant CD4 cell response. Rapid plasma reagin seroreversion was infrequent (16.1%) and inconsistent, and it was more likely to occur among patients who received macrolides.The use of highly active antiretroviral therapy to reverse immunosuppression and the routine use of macrolides for the prevention of opportunistic infections may reduce syphilis serologic failure rates among HIV-infected patients who have syphilis.

Patient-centered care--including the domains of access and communication--is an important determinant of positive clinical outcomes.To explore associations between race and HIV-infected patients' experiences of access and communication.This was a cross-sectional survey.Nine hundred and fifteen HIV-infected adults receiving care at 14 U.S. HIV clinics.Dependent variables included patients' reports of travel time to their HIV care site and waiting time to see their HIV provider (access) and ratings of their HIV providers on always listening, explaining, showing respect, and spending enough time with them (communication). We used multivariate logistic regression to estimate associations between patient race and dependent variables, and random effects models to estimate site-level contributions.Patients traveled a median 30 minutes (range 1-180) and waited a median 20 minutes (range 0-210) to see their provider. On average, blacks and Hispanics reported longer travel and wait times compared with whites. Adjusting for HIV care site attenuated this association. HIV care sites that provide services to a greater proportion of blacks and Hispanics may be more difficult to access for all patients. The majority of patients rated provider communication favorably. Compared to whites, blacks reported more positive experiences with provider communication.We observed racial disparities in patients' experience of access to care but not in patient-provider communication. Disparities were explained by poor access at minority-serving clinics. Efforts to make care more patient-centered for minority HIV-infected patients should focus more on improving access to HIV care in minority communities than on improving cross-cultural patient-provider interactions.

Objective We sought to determine the prevalence of any alcohol use and hazardous alcohol consumption among HIV-infected individuals engaged in care and to identify factors associated with hazardous alcohol use. Methods During 2003, 951 patients were interviewed at 14 HIV primary care sites in the USA. Hazardous drinking was defined as >14 drinks/week or ≥5 drinks/occasion for men and >7 drinks/week or ≥4 drinks/occasion for women. Moderate alcohol use was consumption at less than hazardous levels. We used logistic regression to identify factors associated with any alcohol use and hazardous alcohol use. Results Forty per cent of the sample reported any alcohol use in the 4 weeks prior to the interview; 11% reported hazardous use. In multivariate regression, male sex [adjusted odds ratio (AOR) 1.52 (95% confidence interval, CI, 1.07–2.16)], a college education (compared to

Objective: To investigate trends, patient characteristics, and survival associated with AIDS-defining cancer (ADC) and non-AIDS defining cancer (NADC) in the HAART era. Design: Retrospective analysis of all incident malignancies occurring in 1996-2005 among 2566 patients in an urban HIV clinic. Methods: Clinical profiles of NADC were compared with ADC and the general cohort. Incidence was examined by Poisson analysis. Standardized incidence ratios (SIR) compared cancer risk with that in the general population. Survival was analyzed by Kaplan-Meier and Cox proportional hazards models. Results: Between 1996 and 2005, 138 ADC and 115 NADC were diagnosed. ADC rates decreased from 12.5 to 3.5 cases/1000 person-years (P < 0.001 for trend) while NADC rates increased from 3.9 to 7.1 cases/1000 person-years (P=0.13 for trend). Incidence of the most common NADC was higher than expected, including cancers of the lung [n=29; SIR, 5.5; 95% confidence interval (Cl), 3.7-8.0], liver (n=13, SIR, 16.5; 95% Cl, 8.8-28.2), anus (n = 10; SIR, 39.0; 95% Cl, 18.7-71.7), head and neck (n = 14; SIR, 5.1; 95% Cl, 2.8-8.6), and Hodgkin's lymphoma (n = 8; SIR, 9.8; 95% Cl, 4.2-19.2). Survival after cancer diagnosis did not differ between ADC and NADC. Advanced age was associated with NADC (P< 0.01 for trend) and increased mortality in ADC (age ≥50 years adjusted hazard ratio, 2.21; 95% Cl, 1.00-4.89). Conclusions: Rates of ADC decreased while NADC increased within this cohort. Several NADC occurred at rates significantly higher than expected. Screening and suspicion for NADC should increase in care for HIV-infected patients.

To assess the incidence of and risk factors for acute pancreatitis in HIV-infected patients in the contemporary highly active antiretroviral therapy (HAART) era, we evaluated all cases of acute pancreatitis requiring hospitalization between 1996 and 2006 in patients followed at Johns Hopkins Hospital’s HIV clinic. A nested, case-control analysis was employed for initial episodes of acute pancreatitis, and conditional logistic regression was used to assess risk factors. Of 5970 patients followed for 23,460 person–years (PYs), there were 85 episodes of acute pancreatitis (incidence: 3.6 events/1000 PYs). The incidence of pancreatitis from 1996 to 2000 was 2.6 events/1000 PYs; the incidence from 2001 to 2006 was 5.1 events/1000 PYs (p = 0.0014, comparing rates in two time periods). In multivariate regression, factors associated with pancreatitis included female gender (adjusted odds ratio [AOR] 2.96 [1.69, 5.19]; p = 0.001); stavudine use (AOR 2.19 [1.16, 4.15]; p = 0.016); aerosolized pentamidine use (OR 6.27; [1.42, 27.63]; p = 0.015); and CD4 count less than 50 cells/mm3 (AOR 10.47 [3.33, 32.90]; p = 0.001). Race/ethnicity, HIV risk factor, HIV-1 RNA, and newer non-nucleoside reverse transcriptase inhibitors (NNRTI)- and protease inhibitor (PI)-based HAART regimens were not associated with an increased risk of pancreatitis after adjustment for the above factors. Pancreatitis remains a significant cause of morbidity in the HIV population in the HAART era. Acute pancreatitis is associated with female gender, severe immunosuppression, and stavudine and aerosolized pentamidine usage. Of note, newer antiretrovirals, particularly atazanavir, lopinivir/ritonavir, tenofovir, abacavir, and efavirenz, were not associated with an increased risk of pancreatitis.

Human CD4+ T cell clones and cell lines were shown to lyse recombinant vaccinia virus-infected cells that synthesize the HIV-1 envelope glycoprotein gp160. The processing of endogenously synthesized gp160 for recognition by CD4+ T cells required that the protein, after synthesis on the rough endoplasmic reticulum and during subsequent cellular transport, remain attached to the luminal/extracellular membrane face by a hydrophobic anchor sequence.

In India, data regarding mortality and clinical characteristics of hospitalized HIV-infected patients are sparse, which may limit the effectiveness of new hospital-based HIV programmes providing antiretroviral therapy (ART). The objective of our study was to determine mortality and clinical characteristics of hospitalized HIV-infected individuals in a high HIV prevalence region of India.A retrospective chart review was done of known HIV-infected adults admitted to the Medical Service of a large, public hospital in Pune, India, from January 2002 to November 2003.A total of 655 HIV-infected patients were identified; 489 (74.7%) were male and 4 (0.6%) were on ART. The most common illnesses reported were tuberculosis (55.8%), diarrhoea (4.2%), and alcoholic liver disease (3.7%) . The inpatient mortality was 172 (26.3%). The most common causes of death of the 172 people were tuberculosis (52.9%) and cryptococcal meningitis (7.6%). In multivariate analysis, factors associated with increased mortality were male sex (adjusted odds ratio (AOR) 1.92, 95% CI: 1.08-3.41), haemoglobin level7 g/dl (AOR 2.75, 95% CI:1.23-6.14), length of stay2 days (OR 5.78, 95%, CI: 1.82-18.4), and cryptococcal meningitis (OR 4.44, 95% CI:1.19-16.6).In the era prior to widespread ART, a high inpatient mortality of 26 per cent was found among hospitalized HIV-infected individuals. Thus, while hospitalization is an important access and referral point for HIV care and treatment, earlier identification of HIV-infected persons must occur to ensure they will optimally benefit from the government's ART programme.

Between 2001 and 2004, the percentage of all HIV cases in patients aged ≥50 years increased from 17% to 23%. This concerning increase is expected to continue over the next decade. The increasing prevalence of HIV in these patients is a result of increased longevity in patients treated with highly active antiretroviral therapy (HAART) as well as new primary infections in older patients. While older patients may achieve virological suppression at the same rate as younger patients, the immunological benefit of HAART in older patients may be reduced compared with younger patients. In addition, the toxicities associated with HAART may be worse in older HIV patients, particularly those with underlying renal or hepatic insufficiency. All previous studies evaluating the virological and immunological benefits of HAART in older patients have had relatively small sample sizes and none has compared efficacy or rates of toxicity by HAART treatment class. Co-morbidities are more common in older than in younger patients and can impact on the management of HIV in these patients. Providers must be cognisant of drug-drug interactions and potential adverse effects of HAART regimens when selecting an ideal antiretroviral regimen for older HIV patients. Given the increased longevity and rates of malignancies in HIV-infected patients, providers should also be particularly vigilant in maintaining routine health screening in older HIV patients. Controlled trials on HIV epidemiology, pathogenesis, and therapeutic and clinical outcomes are also needed in older patients. As the HIV-infected population ages, there is a growing need to better determine the effectiveness of HAART in older patients, and to investigate factors associated with a more rapid course of HIV infection in patients aged >50 years.

Background: Previous studies described infective endocarditis (IE) in the era before highly active antiretroviral therapy (HAART); however, IE has not been well studied in the current HAART era. We evaluated the incidence of, risk factors for, clinical presentation, and 1-year outcomes of IE in HIV-infected patients. Methods: We evaluated all cases of IE diagnosed between 1990 and 2002 in patients followed at the Johns Hopkins Hospital outpatient HIV clinic. To identify factors associated with IE in the current era of HAART, a nested case-control analysis was employed for all initial episodes of IE occurring between 1996 and 2002. Logistic regression analyses were used to assess risk factors for IE and factors associated with 1-year mortality. Results: IE incidence decreased from 20.5 to 6.6 per 1000 person-years (PY) between 1990 and 1995 and 1996 and 2002. The majority of IE cases were male (66%), African American (90%), and injection drug users (IDUs) (85%). In multivariate regression, an increased risk of IE occurred in IDUs (AOR, 8.71), those with CD4 counts 100,000 copies/mL (AOR, 3.88). Common presenting symptoms included fever (62%), chills (31%), and shortness of breath (26%). The most common etiologic organism was Staphylococcus aureus (69%; of these 11 [28%] were methicillin resistant). Within 1 year, 16% had IE recurrence, and 52% died. Age over 40 years was associated with increased mortality. Conclusions: IE rates have decreased in the current HAART era. IDUs and those with advanced immunosuppression are more likely to develop IE. In addition, there is significant morbidity and 1-year mortality in HIV-infected patients with IE, indicating the need for more aggressive follow-up, especially in those over 40 years of age. Future studies investigating the utility of IE prophylaxis in HIV patients with a history of IE may be warranted.

We sought to project the lifetime cost of medical care for human immunodefiency virus (HIV)-infected adults using current antiretroviral therapy (ART) standards.Medical visits and hospitalizations for any reason were from the HIV Research Network, a consortium of high-volume HIV primary care sites. HIV treatment drug regimen efficacies were from clinical guidelines and published sources; data on other drugs used were not available. In a computer simulation model, we projected HIV medical care costs in 2004 U.S. dollars.From the time of entering HIV care, per person projected life expectancy is 24.2 years, discounted lifetime cost is Dollars 385,200, and undiscounted cost is Dollars 618,900 for adults who initiate ART with CD4 cell count350/microL. Seventy-three percent of the cost is antiretroviral medications, 13% inpatient care, 9% outpatient care, and 5% other HIV-related medications and laboratory costs. For patients who initiate ART with CD4 cell count200/microL, projected life expectancy is 22.5 years, discounted lifetime cost is Dollars 354,100 and undiscounted cost is Dollars 567,000. Results are sensitive to drug manufacturers' discounts, ART efficacy, and use of enfuvirtide for salvage. If costs are discounted to the time of infection, the discounted lifetime cost is Dollars 303,100.Effective ART regimens have substantially improved survival and have increased the lifetime cost of HIV-related medical care in the U.S.

This study assessed the association between longitudinal patterns of illicit drug use and clinical progression of human immunodeficiency virus (HIV) disease. Confidential computer-based interviews, which addressed illicit drug use and other factors, were completed by HIV-infected participants in Baltimore, Maryland, at 6-month intervals from 1998 onward. To assess this association, the authors used a random-effects model in which clinically defined opportunistic conditions were linked to self-reported periods of drug use, enabling four categories of drug use to be distinguished: nonusers, intermittent users during abstinent periods, intermittent users during active periods, and persistent users. Included in the analysis were 1,851 participants who completed > or = 1 survey. For participants who used drugs intermittently over time, the risk of developing new opportunistic conditions during periods of abstinence was similar to that for those who never used drugs (odds ratio = 1.2, 95% confidence interval: 0.9, 1.7). In contrast, compared with that for nonusers, the risk of opportunistic infection was significantly higher for intermittent drug users during periods of active use (odds ratio = 2.2, 95% confidence interval: 1.4, 2.9) and for persistent drug users (odds ratio = 1.9, 95% confidence interval: 1.2, 2.8). Active drug use is temporally linked to HIV disease progression and mortality. Effectively targeting and treating active substance abuse in HIV treatment settings may provide a mechanism to improve clinical outcomes.

Background: Rapid changes in HIV epidemiology and highly active antiretroviral therapy (HAART) may have resulted in recent changes in patterns of inpatient utilization. Objective: To examine trends in inpatient diagnoses and mortality in HIV patients. Design/Setting/Patients: Serial cross-sectional analyses of HIV patients hospitalized in 1996, 1998, and 2000, using hospital discharge data from the Healthcare Costs and Utilization Project for 12 states. Each hospitalization was classified as an opportunistic illness, complication of injection drug use (IDU), liver-related complication, ischemic heart disease, cerebrovascular disease, non-Pneumocystis carinii pneumonia (PCP), diabetes, or chronic hepatitis C virus (HCV). Main Outcome Measures: Number of hospital admissions, inpatient mortality. Results: We evaluated 316,963 admissions that occurred between 1996 and 2000, with an overall mortality of 7%. Hospitalizations for opportunistic infections significantly decreased from 40% to 27% of all HIV-related admissions. The overall proportion of IDU complications remained relatively stable (6%) each year. Hospitalizations increased for liver-related complications from 8% to 13% and for chronic HCV from 1% to 5% in this period. The number of hospitalizations for cerebrovascular disease and for ischemic heart disease was relatively negligible in all years. Overall, inpatient mortality decreased between 1996 and 2000. Relatively higher mortality was observed among African Americans, Hispanics, those with Medicaid, those with Medicare, and the uninsured, however. Opportunistic infections and liver-related complications were associated with greater inpatient mortality. Conclusion: Results do not show a significant recent rise in HIV-related inpatient utilization. Admissions to treat opportunistic infections have declined precipitously, consistent with the effects of HAART. Although not dramatic, liver-related disease is an increasing cause of hospitalization in HIV+ patients.

Background: Whereas the incidence, risk factors, and clinical sequelae of herpes zoster have been studied in the general population and in HIV patients in the era before highly active antiretroviral therapy (HAART), they have yet to be fully understood in the current era of HAART. Methods: We conducted a retrospective cohort study of patients enrolled in an urban HIV clinic between January 1, 1997 and December 31, 2001. Patients with an episode of herpes zoster during this period were identified, and their charts were reviewed. A nested case-control analysis was used to assess factors associated with an initial episode of herpes zoster. Multivariate conditional logistic regression analyses were used to assess risk factors for zoster. Logistic regression was performed to assess factors associated with complicated zoster. Results: Two hundred eighty-two episodes of herpes zoster were identified in 239 patients. Of these episodes, 158 were new occurrences of zoster and 124 were recurrent zoster events. The incidence of zoster during the study period was 3.2 per 100 person-years of follow-up. The incident cases reflected the clinic population, with most patients being male (63%) and African American (77%) and having injection drug use as their HIV risk factor (49%). The mean age of the patients was 41 years. Sixty-seven percent of patients had single dermatomal involvement, and the thorax was involved in 41%. In multivariate regression, being on HAART (odds ratio [OR] = 2.39, 95% confidence interval [CI]: 1.65 to 3.49) and a CD4 count of 50 to 200 cells/mm 3 (OR = 2.69, 95% CI: 1.44 to 5.01) compared with a CD4 count less than 50 cells/mm 3 were associated with an increased risk of zoster. Twenty-eight patients (18%) developed post-herpetic neuralgia (PHN), and 29 patients (18%) had other complications. Male-to-male sex as an HIV risk factor (P = 0.02) and being on HAART at a zoster episode (P = 0.03) were protective against complicated zoster. Conclusions: Our results suggest that zoster infection rates have not changed in the current HAART era but that a significant percentage of patients develop complications, particularly PHN, which is quite remarkable considering the young age of our population.

The aging of the pediatric HIV cohort and advances in antiretroviral therapy for children may have resulted in recent changes in patterns of healthcare utilization.The objectives of this study were to examine inpatient and outpatient HIV-related health service utilization in a multistate sample of HIV-infected children, and to assess sociodemographic and clinical correlates of utilization.Cohort study of pediatric patients with HIV. Demographic, clinical, and resource utilization data were collected from medical records for 2000 and 2001.This study was conducted at 4 U.S. HIV primary pediatric and specialty care sites in different geographic regions.Three hundred three HIV-positive children with at least one outpatient visit or CD4 test in either 2000 or 2001 were studied.Mean outcome measures were number of hospital admissions, mean length of hospital stay, and number of outpatient clinic/office visits.Hospitalization rates decreased significantly from 39.2 (95% confidence interval [CI], 28.4-50.1) to 25.3 (95% CI, 16.4-34.3) admissions per 100 patients between 2000 and 2001. Hospitalizations were higher among patients with greater immunosuppression, those 2 years and under, and those with AIDS, but were not significantly related to receipt of highly active antiretroviral therapy. Mean outpatient visits did not change significantly between 2000 and 2001 from 9.09 (95% CI, 8.3-9.9) to 9.06 (95% CI, 8.4-9.7) visits per child per year. Children 2 years and under, those on highly active antiretroviral therapy, those with AIDS, and those with Medicaid had significantly higher outpatient utilization. Those with higher HIV-1 RNA had higher outpatient utilization than those with less advanced disease.Inpatient utilization significantly decreased between 2000 and 2001, but outpatient utilization did not change over time. Compared with prior studies, utilization rates appear to be declining over time. Unlike adults, racial/ethnic or gender disparities in healthcare utilization are less pronounced for HIV-infected children.

Background: The goal of highly active antiretroviral therapy (HAART) has been to stabilize and reconstitute immune function and suppress viral replication to the greatest degree possible. Suppression of HIV viral replication has been associated with improved long-term and short-term prognosis. Limited data are available on the level of virologic suppression and immune function of pediatric patients followed in clinical settings in the HAART era. Objective: The objective of this study was to assess the level of virologic suppression and immune function in a cohort of children with perinatally acquired HIV infection followed at dedicated HIV specialty care sites. Research Design: This study comprised a cohort study of HIVinfected children and adolescents. Subjects: Study subjects consisted of 263 HIV-positive children (17 years old), on HAART, with at least one outpatient visit and CD4 test recorded in 2001 seen at 4 U.S. HIV primary pediatrics and specialty care sites (2 eastern, 1 southern, and 1 western). Measures: Measures consisted of all plasma HIV-1 RNA levels 400 during calendar year 2001. Results: Two hundred sixty-three patients received HIV-related treatment during 2001, with a mean age of 8.5 years. Sixty-eight percent were black, 54% were females, and the majority (85%) was insured by Medicaid. A total of 28.6% had a class C AIDS diagnosis. A total of 23.5% and 34% of patients maintained viral suppression at 50 copies per milliliter (cpm), or 400 cpm, respectively, for the calendar year; 32.5% and 38.8%, respectively, fulfilled the criteria if one “blip” to 5000 cpm was allowed. Forty-eight percent maintained all viral loads 5000 cpm, and 74.9% overall had HIV-1 RNAs 15,000 cpm. Eighty-seven percent of patients had CD4% 25; only 4.2% had CD4 15%. Overall, 12.5% of patients had either CD4% 15 or severely decreased absolute CD4 counts (adjusted for age). A total of 4.6% of patients had HIV-1 RNAs 100,000 cpm and severe immunosuppression. Patients who were less likely to achieve virologic suppression to 400 cpm included those with CD4 count 200 cells/mm 3 (odds ratio OR, 0.06; 95% confidence interval CI, 0.007‐0.46), those with AIDS (OR, 0.5; 95% CI, 0.28‐0.94), and those with moderate (OR, 0.42; 95% CI, 0.22‐0.79), or severe immunologic suppression (OR, 0.14; 95% CI, 0.046‐0.43) based on CD4%. Conclusion: In this multisite, pediatric cohort, the rate of nearcomplete virologic suppression (50 or 400 cpm) was low. However, the majority of patients have near-normal CD4 counts and viral loads 15,000 cpm. Follow up will be critical to assess the implications of ongoing low-level viral replication with near-normal CD4 values.

Background: Admissions for AIDS-related illnesses decreased soon after the introduction of highly active antiretroviral therapy (HAART), but it is unclear if the trends have continued in the current HAART era. An understanding of healthcare utilization patterns is important for optimization of care and resource allocation. We examined the diagnoses for hospitalizations of patients with HIV in 2001. Methods: Demographic and healthcare data were collected for 8376 patients from 6 U.S. HIV care sites in 2001. We categorized diagnoses into 18 disease groups and used Poisson regression to analyze the number of admissions for each of the 4 most common groups. We also compared patients with admissions for AIDS-defining illnesses (ADI) with patients admitted for other diagnoses. Results: Twenty-one percent of patients had at least 1 hospitalization. Among patients hospitalized at least once, 28% were hospitalized for an ADI. Comparing diagnosis categories, the most common hospitalizations were AIDS-defining illnesses (21.6%), gastrointestinal (GI) diseases (9.5%), mental illnesses (9.0%), and circulatory diseases (7.4%). In multivariate analysis, women had higher hospitalization rates than men for ADI (incidence rate ratio [IRR], 1.50; 95% confidence interval [CI], 1.25-1.79) and GI diseases (IRR, 1.52; 95% CI, 1.15-2.00). Compared with whites, blacks had higher admission rates for mental illnesses (IRR, 1.70; 95% CI, 1.22-2.36), but not for ADI. As expected, CD4 count and viral load were associated with ADI admission rates; CD4 counts were also related to hospitalizations for GI and circulatory conditions. Conclusions: Five years after the introduction of HAART, AIDS-defining illnesses continue to have the highest hospitalization rate among the diagnosis categories examined. This result emphasizes the importance of vaccination for pneumonia and influenza, as well as prophylaxis for Pneumocystis jiroveci pneumonia. The relatively large number of mental illness admissions highlights the need for comanagement of psychiatric disease, substance abuse, and HIV. Overall, the majority of patients were hospitalized for reasons other than ADI, illustrating the importance of managing comorbid conditions in this population. Data from this cohort of patients with HIV may help guide the allocation of healthcare resources by enhancing our understanding of factors associated with variation in inpatient utilization rates.

Early studies of highly active antiretroviral therapy (HAART) use in clinical practice suggested suboptimal rates of viral suppression. HAART regimens and expertise in the use of HAART have since evolved, and we sought to determine how virologic response to HAART has changed in clinical practice. We compared all patients who started a first HAART regimen from 1996 through 2002 in a longitudinal cohort of HIV-infected patients in care in Baltimore. There were significant improvements in suppressing HIV RNA to400 copies/mL, ranging from 43.8% (1996) to 72.4% (2001-2002) by 6 months and from 60.1% (1996) to 79.9% (2001-2002) by 12 months (both P0.01 for trend). There were also significant improvements in CD4 cell response. Over time, there was a significant increase in the use of a nonnucleoside reverse transcriptase inhibitor (NNRTI) or boosted protease inhibitor (PI) regimen compared with a single PI as well as an increase in the number of patients who were antiretroviral (ARV) naive. There was also a significant temporal trend from 1996 through 2002 in achieving a suppressed HIV RNA level, adjusting for being ARV naive, specific HAART regimen, CD4 cell count, HIV-1 RNA level, and demographic factors. This suggests that improved virologic response may also be attributable to other factors such as a greater focus on medication adherence, improved ARV tolerability, and ease of dosing.

Background: Psychiatric disorders are common in HIV patients, and previous work suggests that these patients experience delays in treatment with highly active antiretroviral therapy (HAART). We investigated whether a current psychiatric disorder (1) affected the time to initiation of HAART, (2) predicted the likelihood of being prescribed HAART for at least 6 months, and (3) affected survival in urban AIDS patients. Methods: We conducted a retrospective cohort study of AIDS patients with no prior history of HAART who were enrolled and followed at the Johns Hopkins University HIV clinic between January 1996 and January 2002. Patients were stratified based on the presence of a psychiatric disorder. Cox proportional hazards regression models estimated the relative risk of receiving HAART and survival, whereas multivariate logistic regression models estimated the relative odds of remaining on HAART. Results: During the study period, 549 patients with AIDS anc no prior antiretroviral treatment were enrolled in the clinic. Eighteen percent (n = 100) were defined as having a current psychiatric disorder, 39% (n = 215) were defined as having no psychiatric disorder, and 43% (n = 34) were indeterminate. Patients with a psychiatric disorder were 37% more likely to receive HAART (Cox adjusted hazard ratio [95% confidence interval (CI)]: 1.37 [1.01-1.87]), had greater than twice the odds of being prescribed HAART for at least 6 months (adjusted odds ratio [95% CI]: 2.14 [1.24-3.69]), and were 40% more likely to survive (Cox adjusted hazard ratio [95% CI]: 0.61[0.37-0.99]) as compared with those without a psychiatric disorder. Conclusion: Patients with psychiatric disorders are receiving HAART and are able to reap the survival benefit by remaining on it.

The prevalence of esp, a gene associated with infection-derived and outbreak strains, in enterococcal blood isolates from 2002 was determined. Fifty-five of 137 (40.1%) Enterococcus faecalis isolates, 30 of 58 (51.7%) E. faecium isolates, 1 of 1 E. raffinosus isolate, 0 of 4 E. gallinarum isolates, and 0 of 1 E. casseliflavus isolate were positive. esp wasn't associated with vancomycin resistance (VR) or clinical service. VR E. faecium isolates were less genetically diverse than vancomycin-susceptible strains. A large cluster of VR isolates, belonging to esp -positive E. faecium , was revealed. These data support the hypothesis that esp and VR may contribute to dissemination of particular clones.

Objective: To determine whether hepatitis C virus (HCV) infection status affected hospitalization rates, intensive care utilization rates, and discharge diagnoses between 1995 and 2000 in patients with HIV. Methods: We conducted a prospective cohort study of 3730 HIV patients who were longitudinally followed between 1995 and 2000. All hospitalizations of these patients were classified as an opportunistic illness (OI) using the 1993 indicator diagnoses in the case definition of AIDS, complication of injection drug use (IDU) (abscess, cellulitis, osteomyelitis, bacteremia, endocarditis, and poisoning by analgesics), liver-related complication (acute and subacute necrosis of the liver, chronic liver disease and cirrhosis, liver abscess, hepatic coma, portal hypertension, hepatorenal syndrome, hepatocellular carcinoma, and gastrointestinal bleed), or other. Negative binomial regression was used to assess for risk factors for hospitalization. Main Outcome Measures: Inpatient hospitalization and intensive care utilization rates and discharge diagnoses. Results: Nearly half (42.8%) of our cohort was infected with HCV. Between 1995 and 2000, hospitalization rates for HCV-negative patients decreased from 61.9 to 33.9 per 100 patient-years (PY) of follow-up (P = 0.007). Hospitalization rates decreased between 1995 and 1997 for HCV-positive patients from 55.4 to 43.5 per 100 PY but increased between 1997 and 2000 from 43.5 to 62.9 per 100 PY (P = 0.001). When stratified by diagnostic category, IDU-related complications increased from 13.6 to 18.4 admissions per 100 PY and liver-related complications increased from 5.4 to 26.7 admissions per 100 PY between 1995 and 2000 in HCV-positive patients (P < 0.001); however, Ols remained relatively unchanged from 1995 to 2000, with 14.6 to 13.0 hospitalizations per 100 PY. In multivariate analysis, HCV infection (incidence rate ratio [IRR] = 1.75, 95% confidence interval [CI]: 1.47, 2.07 female gender (IRR = 1.56, 95% CI: 1.32, 1.85), age

Background: The evolving epidemiology and therapeutic management of HIV disease has important implications for health care resource utilization in HIV-infected patients, and health care resource use data are also needed to support policy and financial decision making.Methods: Demographic, clinical, and resource utilization data were collected from 9 U.S. HIV primary and specialty care sites in calendar year 1999. Rates of resource use were calculated for hospital admission, length of hospital stay, and outpatient clinic/office visits.Results: The sample included 5255 patients from HIV primary care sites in 3 eastern, 3 midwestern, arid 3 western areas of the United States. Hospital admissions accounted for an annual mean of 297 days per 100 persons/y in 1999. Hospital days ranged from a low of 165 per 100 persons/mo for a CD4 > 500 cells/mm(3) to 840 per 100 persons/mo for a CD4 < 50 cells/mm(3) (p < .01). Mean annual outpatient clinic/office visits were 10.7 per person in 1999. A declining CD4 level and an increasing HIV-1 RNA level were both associated with higher hospital and outpatient utilization. HAART use was associated with fewer hospital days, and a higher outpatient visit rate. Injecting drug use risk was associated with an increase in hospital days. African American race was associated with a higher number of hospital days, but a lower outpatient visit rate. Female gender was associated with higher outpatient utilization. Mean monthly inpatient and outpatient expenditures in 1999 were $423 and $168, respectively.Conclusion: As HIV care continues to evolve, data from our network of HIV providers will be useful in quantifying changes in HIV health services utilization makers, as well as HIV care payers and providers.

Infection Control surveillance revealed an abnormally high number of sputum samples growing Mycobacterium fortuitum from a single ward that houses the human immunodeficiency virus service. We investigated the outbreak using a retrospective case-control study and molecular epidemiology. A total of 47 patients were identified with >/=1 sputum sample that grew M. fortuitum. No significant demographic or clinical variables were found to be associated with colonization. Environmental investigation demonstrated that the M. fortuitum isolated from patients was identical to the ice machine isolates by pulsed-field gel electrophoresis. Fortunately, there has been no evidence of progressive pulmonary disease developing in our patients after >/=6 months of follow-up. All cases were thought to represent transient colonization and not infection. The ice machine was disconnected and cleaned successfully with vinegar and then bleach. Only when a 0.5-micrometer filter was installed were no further patients colonized or water cultures found to be positive.

Objective: Previous studies have shown a decrease in hospitalization rates associated with the introduction of highly active antiretroviral therapy (HAART). To evaluate hospitalization rates and patterns in discharge diagnoses that changed between 1995 and 1998 and to examine risk factors for hospitalization in HIV-positive patients, we conducted a cohort study. Patients and Methods: All inpatient hospitalizations of 2,151 HIV-positive patients enrolled in our university-based HIV clinic between January I, 1994 and December 31, 1998 with a CD4 count within a 6-month calendar semester were examined to evaluate hospitalization rates, discharge diagnoses, and intensive care department use. Negative binomial regression was used to assess the effect of various risk factors on hospitalization. Results: Hospitalization rates decreased between 1995 and 1996 but increased between 1997 and 1998. In multivariate regression, female gender (incidence rate ratio [IRR], 1.45; p

To explore the utility of peer review (review by fellow interns or residents in the firm) as an additional method of evaluation in a university categorical internal medicine residency program.Senior residents and interns were asked to complete evaluations of interns at the end-of-month ward rotations.Response rates for senior residents evaluating 16 interns were 70%; for interns evaluating interns, 35%. Analysis of 177 instruments for 16 interns showed high internal consistency in the evaluations. Factor analysis supported a two-dimensional view of clinical competence. Correlations between faculty, senior resident, and intern assessments of interns were good, although varied by domain.An end-of-year attitude survey found that residents gave high ratings to the value of feedback from peers.

Objectives The prevalence of biologic false-positive (BFP) non-treponemal tests ranges from 4–15% among HIV-infected persons. Abnormalities in B cell function are hypothesised to increase the probability of BFP in this population. Our aim was to determine the impact of combination antiretroviral therapy (cART) and the degree of immunosuppression on BFP Rapid Plasma Reagin (RPR) tests among HIV-infected persons. Methods We conducted a retrospective study of 711 HIV-infected patients enrolled in the Johns Hopkins HIV Clinical Cohort. BFP RPR was defined as a reactive RPR and a non-reactive FTA-ABS. We conducted two analyses: (1) A cross-sectional analysis in which patients with BFP tests were compared to two control groups: HIV-infected patients (i) with syphilis and (ii) without syphilis. (2) A longitudinal analysis to determine the factors associated with BFP persistence over time. A persistent BFP test was defined as a BFP test at all visits in patients who had more than one visit with a documented RPR test. We used logistic regression and Generalized Estimating Equations for the analyses. Results 96 participants (13.5%) had BFP tests and 273 (48.1%) had syphilis. Twenty-two of 96 (23%) had persistent BFP tests. cART use was associated with decreased odds of BFP tests compared to persons with syphilis [adjusted odds ratio (aOR) 0.31, 95% CI: 0.15–0.63] and without syphilis [aOR 0.42 (0.22–0.81)]. cART use was also associated with decreased odds of BFP persistence over time [OR 0.07 (0.01–0.33)]. Neither CD4 count nor HIV RNA was associated with BFP test results. Lower RPR titers, injection drug use and Hepatitis B were associated with increased odds of BFP. Conclusions The use of cART appears to significantly decrease the odds of BFP RPR tests, independent of CD4 T-cell response. This may be the result of cART’s effects on B-cell functions.

To identify risk factors for pneumococcal infection among human immunodeficiency virus-infected patients, a nested case-control study was done in an urban university human immunodeficiency virus clinic. Subjects with pneumococcal illness seen between 1 January 1990 and 1 July 1994 (n=85) were randomly matched to controls from the same population. Patients with pneumococcal disease were more likely than controls to be African Americans (adjusted odds ratio [OR]=3.92), have200 CD4 cells/mm3 (adjusted OR=3.38), have a history of any pneumonia (adjusted OR=3.28), and have an albumin level of3.0 g/dL (adjusted OR=6.25). Use of zidovudine (adjusted OR=0.38) and pneumococcal vaccination when the subject had200 CD4 cells/mm3 (adjusted OR=0.22) were less common in cases than in controls. Similar results were found when only cases with infections of usually sterile sites were analyzed. Pneumococcal vaccine may be most protective when it is administered before advanced immunodeficiency develops.

To The Editor—We thank Holtzman and Gallagher for their interest in our work [1]. Consistent with our study, which identified antiretroviral (ARV) medication errors in 29% of admissions during the first hospital day [2], they report an error rate of 26% among hospitalized human immunodeficiency virus (HIV)–infected patients prescribed ARV medications at Temple University Hospital in Philadelphia, PA [1]. We would like to clarify a misunderstanding by Holtzman and Gallagher of our study methods. As we stated in the methods section of our paper, our study was a retrospective review of ARV medication errors, and not an evaluation of a pharmacist intervention [2]. Two clinical pharmacists retrospectively reviewed medical orders to identify ARV medication errors for study purposes, and were not present in real time to identify and correct medication errors. At Johns Hopkins Hospital, the HIV/AIDS service has a specialized clinical pharmacist who reviews all medications administered on the prior day. However, our study included not only patients admitted to the HIV/AIDS service, but also those admitted to medicine, surgery, obstetrics and gynecology, neurology, and psychiatry. These other services do not routinely include pharmacists on the rounding team. Since we did not specifically evaluate a clinical pharmacist intervention on medication orders, we offered clinical pharmacy review of medication orders as a possible reason for the decline in errors on the second day of hospitalization for two reasons: (1) prior studies have demonstrated the efficacy of clinical pharmacists in decreasing ARV medication errors [3], and (2) 64% of our study patients were admitted to the HIV/AIDS service, which has a dedicated HIV clinical pharmacist. Other interventions, both educational and technological, may also be important to correcting ARV medication errors that occur early in hospitalization.

We assessed CD4 count at initial presentation for HIV care among ≥50-year-olds from 1997-2007 in 13 US and Canadian clinical cohorts and compared to 3) and 95% confidence intervals ([,]) were determined using linear regression stratified by age category and adjusted for gender, race/ethnicity, HIV transmission risk and cohort. From 1997-2007, the proportion of individuals presenting for HIV care who were ≥50-years-old increased from 17% to 27% (p-value < 0.01). The median CD4 count among ≥50 year-olds was consistently lower than younger adults. The interaction of age group and calendar year was significant (p-value 3; ≥50-year-olds: 7 [5 , 9] cells/mm3), after adjusting for sex, race/ethnicity, HIV transmission risk group and cohort; however, increases in the two groups were similar after 2000. A greater proportion of older individuals had an AIDS-defining diagnosis at, or within three months prior to, first presentation for HIV care compared to younger individuals (13% vs. 10%, respectively). Due to the increasing proportion, consistently lower CD4 counts, and more advanced HIV disease in adults ≥50-year-old at first presentation for HIV care, renewed HIV testing efforts are needed.

Background Rapid changes in HIV epidemiology and antiretroviral therapy may have resulted in recent changes in patterns of healthcare utilization. Objective The objective of this study was to examine sociodemographic and clinical correlates of inpatient and outpatient HIV-related health service utilization in a multistate sample of patients with HIV. Design Demographic, clinical, and resource utilization data were collected from medical records for 2000, 2001, and 2002. Setting This study was conducted at 11 U.S. HIV primary and specialty care sites in different geographic regions. Patients In each year, HIV-positive patients with at least one CD4 count and any use of inpatient, outpatient, or emergency room services. Sample sizes were 13,392 in 2000, 15,211 in 2001, and 14,403 in 2002. Main outcome measures Main outcome measures were number of hospital admissions, total days in hospital, and number of outpatient clinic/office visits per year. Inpatient and outpatient costs were estimated by applying unit costs to numbers of inpatient days and outpatient visits. Results Mean numbers of admissions per person per year decreased from 2000 (0.40) to 2002 (0.35), but this difference was not significant in multivariate analyses. Hospitalization rates were significantly higher among patients with greater immunosuppression, women, blacks, patients who acquired HIV through drug use, those 50 years of age and over, and those with Medicaid or Medicare. Mean annual outpatient visits decreased significantly between 2000 and 2002, from 6.06 to 5.66 visits per person per year. Whites, Hispanics, those 30 years of age and over, those on highly active antiretroviral therapy (HAART), and those with Medicaid or Medicare had significantly higher outpatient utilization. Inpatient costs per patient per month (PPPM) were estimated to be 514 dollars in 2000, 472 dollars in 2001, and 424 dollars in 2002; outpatient costs PPPM were estimated at 108 dollars in 2000, 100 dollars in 2001, and 101 dollars in 2002. Conclusion Changes in utilization over this 3-year period, although statistically significant in some cases, were not substantial. Hospitalization rates remain relatively high among minority or disadvantaged groups, suggesting persistent disparities in care. Combined inpatient and outpatient costs for patients on HAART were not significantly lower than for patients not on HAART.