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Objectives. We sought to determine the prevalence of HIV in both inpatient and outpatient settings in 6 Department of Veterans Affairs (VA) health care sites. Methods. We collected demographic data and data on comorbid conditions and then conducted blinded, anonymous HIV testing. We conducted a multi-variate analysis to determine predictors of HIV infection. Results. We tested 4500 outpatient blood specimens and 4205 inpatient blood specimens; 326 (3.7%) patients tested positive for HIV. Inpatient HIV prevalence ranged from 1.2% to 6.9%; outpatient HIV prevalence ranged from 0.9% to 8.9%. Having a history of hepatitis B or C infection, a sexually transmitted disease, or pneumonia also predicted HIV infection. The prevalence of previously undocumented HIV infection varied from 0.1% to 2.8% among outpatients and from 0.0% to 1.7% among inpatients. Conclusions. The prevalence of undocumented HIV infection was sufficiently high for routine voluntary screening to be cost effective in each of the 6 sites we evaluated. Many VA health care systems should consider expanded routine voluntary HIV screening. (Am J Public Health. 2007;97:2173-2178. doi:10.2105/AJPH. 2007.110700) [ABSTRACT FROM AUTHOR]

Objective: Early identification of HIV infection is critical for patients to receive life-prolonging treatment and risk-reduction counseling. Understanding HIV screening practices and barriers to HIV testing is an important prelude to designing successful HIV screening programs. Our objective was to evaluate current practice patterns for identification of HIV.Methods: We used a retrospective cohort analysis of 13,991 at-risk patients seen at 4 large Department of Veterans Affairs (VA) health-care systems. We also reviewed 1,100 medical records of tested patients. We assessed HIV testing rates among at-risk patients, the rationale for HIV testing, and predictors of HIV testing and of HIV infection.Results: Of the 13,991 patients at risk for HIV, only 36% had been HIV-tested. The prevalence of HIV ranged from 1% to 20% among tested patients at the 4 sites. Approximately 90% of patients who were tested had a documented reason for testing.Conclusion: One-half to two-thirds of patients at risk for HIV had not been tested within our selected VA sites. Among tested patients, the rationale for HIV testing was well documented. Further testing of at-risk patients could clearly benefit patients who have unidentified HIV infection by providing earlier access to life-prolonging therapy. [ABSTRACT FROM AUTHOR]

BACKGROUND: Little is known about the health burden of chronic viral hepatitis in HIV-infected patients. We compared health-related quality of life (HRQOL) of patients with HIV and hepatitis C virus (HCV) or HIV and hepatitis B virus (HBV) coinfection to those with HIV monoinfection. METHODS: Using a nationally representative sample of 1,874 adults with HIV who completed a baseline and two follow-up interviews, we identified those with HIV monoinfection (n = 1,493), HIV–HCV coinfection (n = 279), and HIV–HBV coinfection (n = 122). We measured baseline and change over time scores for physical and mental health (PHS, MHS), overall quality of life (QOL), overall health, and disability days. To identify the independent effect of coinfection, we adjusted for demographic and clinical predictors of HRQOL using multivariable regression. RESULTS: Despite significant differences in socio-demographic characteristics between groups, there were no differences in the baseline scores for PHS, MHS, overall QOL, overall health, or disability days between groups. The HRQOL did not decline significantly over time for the HIV patients with or without HCV or HBV coinfection. All groups reported similar longitudinal changes in the HRQOL scores for all measures. CONCLUSIONS: We found no significant differences in disease burden as assessed by a generic HRQOL instrument between patients with HIV monoinfection and HIV–HCV or HIV–HBV coinfection. These data are relevant in counseling coinfected patients regarding the impact of coinfection on HRQOL, and are important in designing clinical trials and conducting cost-effectiveness analyses including this vulnerable cohort. (Am J Gastroenterol 2005;100:1–11) [ABSTRACT FROM AUTHOR]

Objectives: Both clinical trials and observational studies of persons with HIV infection commonly include health-related quality of life (HRQOL) measures, but less is known about the relation of HRQOL to survival among persons with HIV since the development of effective antiretroviral treatment.Design/participants: Prospective cohort study of a national probability sample of 2,864 adults receiving HIV care.Independent Variables: The main independent variables were derived from the HIV Cost and Services Utilization Study (HCSUS) HRQOL measure, and include physical and mental HRQOL summary scores (divided into quartiles) constructed from the following items administered at baseline: physical functioning (9 items, alpha=0.91), role functioning (2 items, alpha=0.85), pain (2 items, alpha=0.84), general health perceptions (3 items, alpha=0.80), emotional well-being (7 items, alpha=0.90), social functioning (2 items, alpha=0.82), energy (2 items, alpha=0.74), and a single-item measure of disability days (days in bed for at least 0.5 day due to health).Main Outcome Variable: Death between January 1996 and December 1999.Analysis: Descriptive and multivariate adjusted Cox proportional hazards regression analysis of survival by physical and mental HRQOL.Results: By December 1999, 17% of the sample had died. In unadjusted analysis, persons in the higher quartiles of physical HRQOL, as well as those in the higher quartiles of mental HRQOL at baseline, had significantly better survival than those in lower quartiles. In multiple regressions controlling for a number of sociodemographic and clinical variables, the hazard of death for those in the highest quartile of physical HRQOL was one quarter of that for those in the lowest quartile. This difference was similar in magnitude to that observed for being on highly active antiretroviral therapy versus no antiretrovirals in this population. By contrast, there was no unique association of mental HRQOL with survival.Conclusions: Physical HRQOL added prognostic information over and above the sociodemographic and routinely available clinical data such as CD4 count and stage of HIV infection. Measurement of HRQOL, which is often performed to identify problems or assess outcomes, is also useful prognostically. [ABSTRACT FROM AUTHOR]

Objective: To determine the sociodemographic and service delivery correlates of depression underdiagnosis in HIV.Design: Cross-sectional survey.Patients/participants: National probability sample of HIV-infected persons in care in the contiguous United States who have available medical record data.Measurements and Main Results: We interviewed patients using the Composite International Diagnostic Interview (CIDI) survey from the Mental Health Supplement. Patients also provided information regarding demographics, socioeconomic status, and HIV disease severity. We extracted patient medical record data between July 1995 and December 1997, and we defined depression underdiagnosis as a diagnosis of major depressive disorder based on the CIDI and no recorded depression diagnosis by their principal health care provider in their medical records between July 1995 and December 1997. Of the 1140 HIV Cost and Services Utilization Study patients with medical record data who completed the CIDI, 448 (37%) had CIDI-defined major depression, and of these, 203 (45%) did not have a diagnosis of depression documented in their medical record. Multiple logistic regression analysis revealed that patients who had less than a high school education (P <.05) were less likely to have their depression documented in the medical record compared to those with at least a college education. Patients with Medicare insurance coverage compared to those with private health insurance (P <.01) and those with >or=3 outpatient visits (P <.05) compared to <3 visits were less likely to have their depression diagnosis missed by providers.Conclusions: Our results suggest that providers should be more attentive to diagnosing comorbid depression in HIV-infected patients. [ABSTRACT FROM AUTHOR]

Background: Since the introduction of the first protease inhibitor in January 1996, there has been a dramatic change in the treatment of persons infected with HIV. The changing nature of HIV care has important implications for the types of physicians that can best care for patients with HIV infection.Objective: To assess the association of specialty training and experience in the care of HIV disease with the adoption and use of highly active antiretroviral (ARV) therapy (HAART).Design: Observational cohort study of patients under care for HIV infection and their physicians.Patients and Setting: This analysis used data collected from a national probability sample of noninstitutionalized persons with HIV infection participating in the HIV Costs and Service Utilization Study and their primary physicians. We analyzed 1,820 patients being cared for by 374 physicians.Measurements: Rates of HAART use at 12 months and 18 months after the approval of the first protease inhibitor.Results: Forty percent of the physicians were formally trained in infectious diseases (ID), 38% were general medicine physicians with self-reported expertise in the care of HIV, and 22% were general medicine physicians without self-reported expertise in the care of HIV. The majority of physicians (69%) reported a current HIV caseload of 50 patients or more. In multivariable models controlling for patient characteristics, there were no differences between generalist experts and ID physicians in rates of HAART use in December 1996. When compared to ID physicians, however, patients being treated by non-expert general medicine physicians were less likely to be on HAART (odds ratio [OR], 0.32; 95% confidence interval [95% CI], 0.17 to 0.61). Patients being treated by low-volume physicians were also much less likely to be on HAART therapy than those treated by high-volume physicians (OR, 0.26; 95% CI, 0.14 to 0.48). These findings were attenuated by June 1997, suggesting that over time, the broader physician community successfully adopted HAART therapy. This finding is consistent with prior research on the diffusion of innovations.Conclusions: Similar proportions of patients treated by expert generalists and ID specialists were on appropriate HAART therapy by December 1996 and July 1997. Patients treated by non-expert generalists, most of whom were the lowest-volume physicians, were much less likely to be on appropriate ARV therapy in the earlier time period. Our findings demonstrate that expert generalists who develop specialized expertise are able to provide care of quality comparable to that of specialists. [ABSTRACT FROM AUTHOR]

Context: Little is known about HIV patients' care experiences.Objective: To assess HIV patients' experiences with inpatient and outpatient care, and to assess the relationship and relative influence of patient characteristics and site of care on care experiences.Design: Cohort study.Setting: Patients with HIV receiving care outside of emergency rooms, prisons, or the military throughout the continental United States. One thousand seventy-four patients provided ratings of an inpatient stay and 2204 rated an outpatient visit; 818 patients provided evaluations of both inpatient and outpatient care.Patients: A national probability sample of persons in care for HIV from the HIV Cost and Services Utilization Study.Measurements: Outcome variables were rates of problems with, and global ratings of, inpatient and outpatient care.Results: Mean problem rates were 20.9% and 8.4% (lower score means fewer problems) for inpatient and outpatient care, respectively. On 9 of 10 of the individual inpatient report items, 15% or more of respondents reported problems. Global ratings of inpatient and outpatient care were 65.3 and 75.0 (0-100 scale, higher scores indicate better ratings), respectively. In multivariable models that controlled for site effects, the only patient characteristic that was consistently associated with problem rates and global ratings of care was mental health (P <0.0001 for both inpatient and outpatient care). Models including site effects explained two to four times as much variance as models excluding site effects.Conclusions: Inpatients with HIV reported higher problem rates with inpatient than outpatient care. Better provider-patient communication during inpatient stays is needed. For both inpatient and outpatient care, quality improvement efforts may be most productively focused on providers and processes of care at sites rather than on specific patient subgroups. [ABSTRACT FROM AUTHOR]

Objective: To assess the association of specialty training and experience in the care of HIV disease with HIV-specific knowledge, referral patterns, and HIV-related education activities.Design: Cross-sectional survey.Setting: The United States.Participants: Physicians caring for patients in the HIV Costs and Service Utilization Study, a study of a probability sample of HIV-infected individuals in the United States.Measurements and Main Results: Measures included physicians' reports of specialty training and HIV caseload, scores on an HIV-specific knowledge test, referral patterns, and attendance rates at HIV-related educational activities. Approximately 72% (379) of the eligible physicians completed a survey. Of these, 152 (40%) had infectious disease (ID) training, and 213 (56%) were generalists; 4% of ID-trained physicians and 37% of generalist physicians did not consider themselves HIV experts. The median current caseloads were 150 and 200 patients for ID experts and generalist experts, respectively. In contrast, the median caseload for non-expert generalists was 5. Mean scores on the knowledge scale were similar for ID and generalist experts (9.0 items correct out of 11 vs 8.5; P=not significant), but lower for generalist non-experts (6.5 items correct; P <.01). Experts had attended more local and national HIV meetings than non-experts (9.3 vs 2.7; P <.01, and 2.3 vs.40; P <.01, respectively) in the past year. Fewer ID experts ever referred than generalist experts (13.0% vs 27.3%; P=.01). In multivariable models that included specialty training and caseload, physicians with caseloads of 20 to 49 and >50 were more likely to have a high knowledge score (defined as 80% or more correct, odds ratio [OR], 2.8; P=.04 and OR, 5.7; P <.001, respectively), and the effect of specialty was attenuated (OR, 2.7; P=.02 decreased from OR, 7.8; P <.001 in a model without caseload). In the models predicting referral practices, both experience (OR,.25; P <.01 and OR,.17; P <.01 for caseloads of 20 to 49 and >50, respectively) and specialty (OR,.19; P <.01 and OR,.09; P <.01 for generalist and ID experts, respectively) were significant.Conclusions: In a national sample of physicians, HIV-specific knowledge was more strongly associated with HIV caseload than with specialty training. In addition, although referral practices were related to both experience and specialty, generalist experts and ID physicians reported similar behaviors. This suggests that generalist physicians, through clinical experience and self-education, can develop specialized knowledge in HIV care. [ABSTRACT FROM AUTHOR]

Investigates the effect of case management on unmeet needs and utilization of medical care and medications among HIV-infected persons in the United States. Decrease of unmeet need for supportive services; Insignificance of case managers on medical care utilization; Association between the contact of case managers and the use of antiretroviral regimens.

Objective: To distinguish the effects of drug abuse, mental disorders, and problem drinking on antiretroviral therapy (ART) and highly active ART (HAART) use.Design: Prospective population-based probability sample of 2,267 (representing 213,308) HIV-infected persons in care in the United States in early 1996.Measurements: Self-reported ART from first (January 1997-July 1997) to second (August 1997-January 1998) follow-up interviews. Drug abuse/dependence, severity of abuse, alcohol use, and probable mental disorders assessed in the first follow-up interview. Adjusted odds ratios (AORs) and 95% confidence intervals (CIs) estimated from weighted models for 1) receipt of any ART, and 2) receipt of HAART among those on ART.Results: Of our study population, ART was reported by 90% and HAART by 61%. Over one third had a probable mental disorder and nearly half had abused any drugs, but drug dependence (9%) or severe abuse (10%) was infrequent. Any ART was less likely for persons with dysthymia (AOR, 0.74; CI, 0.58 to 0.95) but only before adjustment for drug abuse. After full adjustment with mental health and drug abuse variables, any ART was less likely for drug dependence (AOR, 0.58; CI, 0.34 to 0.97), severe drug abuse (AOR, 0.52; CI, 0.32 to 0.87), and HIV risk from injection drug use (AOR, 0.55; CI, 0.39 to 0.79). Among drug users on ART, only mental health treatment was associated with HAART (AOR, 1.57; CI, 1.11 to 2.08).Conclusions: Drug abuse-related factors were greater barriers to ART use in this national sample than mental disorders but once on ART, these factors were unrelated to type of therapy. [ABSTRACT FROM AUTHOR]

Timely access to medical care is important for HIV+ individuals. Standards of care are needed that identify inappropriate delays in receiving care for serious symptoms. We evaluated the reliability and construct validity of provider-based standards for timely care for HIV symptoms, and applied these standards to data from the HIV Cost and Services Utilization Study (HCSUS), a national probability sample of HIV+ persons in care. HIV physicians estimated appropriate time to care HIV+ individuals should receive for headache, cough, diarrhea, or weight loss. Timely care was defined as receiving care by the mean provider-specified acceptable number of days to care, by specific CD4 count, compared to receiving care after the mean days to care. Sensitivity analyses were performed on the provider standards. Inter-rater reliability between physicians for timely care estimates was high (0.97). Up to 70% of HIV+ individuals from the HCSUS survey did not receive timely care for their most bothersome symptom. Physicians rated patients with lower CD4 counts (<200 cells/ml) as requiring care within a shorter period of time. However, patients with lower CD4 counts (<200 cells/ml) were no more likely or less likely to receive timely care. Physicians considered headache and cough more urgent than weight loss. Yet patients with headache or cough were the least likely to receive timely care. In a national probability sample, time to care for a majority of HIV patients for their most bothersome symptoms exceeded provider-based standards. Further research is needed on reasons for this mismatch. [ABSTRACT FROM AUTHOR]

Objective: To assess the propensity of HIV-infected adults to seek care for common symptoms, and to determine whether they would seek care in the emergency department (ED) or with their primary care provider.Design: Cross-sectional interview study.Setting: Patients in care in the 48 contiguous United States.Participants: A nationally representative group of HIV- infected adults selected using multistage probability sampling.Measurements: Subjects were interviewed between January 1996 and April 1997. Patients with advanced disease (past AIDS diagnosis and/or CD4 cell count <200/microL) and early disease were asked how they would seek care for key HIV-associated symptom complexes. Three advanced disease and 3 early disease symptom scenarios were used.Main Results: Most advanced disease patients (78% to 87%) would seek care right away from the ED or primary care provider for the symptoms asked. Most early disease patients (82%) would seek care right away for new respiratory symptoms; fewer would do so for headache (46%) or oral white patches (62%). In a multivariate model, independent predictors of propensity to use the ED for advanced disease symptoms included African-American ethnicity (adjusted odds ratio [OR], 2.5; 95% confidence interval [95% CI], 1.8 to 3.4); less education (adjusted OR, 1.4; 95% CI, 1.1 to 1.7); drug dependence (adjusted OR, 1.4; 95% CI, 1.1 to 1.7); annual income less than $5,000 (adjusted OR, 1.5; 95% CI, 1.0 to 2.3); and lower psychological well-being (adjusted OR, 0.9; 95% CI, 0.9 to 1.0). In early disease, the following independently predicted ED use: African American (adjusted OR, 4.7; 95% CI, 3.1 to 7.1) or Hispanic ethnicity (adjusted OR 2.4; 95% CI, 1.4 to 4.3), female gender (adjusted OR, 1.6; 95% CI, 1.2 to 2.2), annual income less than $5,000 (adjusted OR, 1.8; 95% CI, 1.1 to 3. 0), and lower psychological well-being (adjusted OR, 0.9; 95% CI, 0. 8 to 1.0).Conclusions: Many patients would use the ED instead of same-day primary care for several common symptoms of HIV disease. African Americans, the poor, and patients with psychological symptoms had a higher propensity to use the ED. [ABSTRACT FROM AUTHOR]

We compared the efficacy of a 400-mg once-weekly dosage versus a 200-mg daily dosage of fluconazole for the prevention of deep fungal infections in a multicenter, randomized, double blind trial of 636 human immunodeficiency virus-infected patients to determine if a less intensive fluconazole regimen could prevent these serious but relatively infrequent complications of AIDS. In the intent-to-treat analysis, a deep fungal infection developed in 17 subjects (5.5%) randomly assigned to daily fluconazole treatment and in 24 (7.7%) given weekly fluconazole during 74 weeks of follow-up (risk difference, 2.2%; 95% confidence interval [CI], −1.7% to 6.1%). Thrush occurred twice as frequently in the weekly versus daily fluconazole recipients (hazard ratio, 0.59; 95% CI, 0.40–0.89), and in a subset of patients evaluated, fluconazole resistance was infrequent. Fluconazole administered once weekly is effective in reducing deep fungal infections in patients with AIDS, but this dosage is less effective than the 200-mg-daily dosage in preventing thrush. [ABSTRACT FROM PUBLISHER]

Treatment of cryptococcal meningitis with amphotericin B or fluconazole is often unsuccessful; in only 35%–40% of cases do CSF cultures become negative by 10 weeks after initiation of such therapy. We conducted a prospective, open-label clinical trial involving persons with AIDS to determine whether the rate of clinical success would improve when fluconazole (400 mg daily) was combined with flucytosine (150 mg/kg daily). At the conclusion of 10 weeks of therapy, 75% (95% confidence interval, 58%–87%) of 32 subjects' CSF cultures were negative. The Kaplan-Meier estimate of clinical success at 10 weeks was 63% (95% confidence interval, 48%–82%). The median time to negativity of the CSF culture was 23 days. Toxic side effects that were sufficiently severe to lead to the withdrawal of flucytosine were observed in nine subjects (28%). In this pilot study of fluconazole combined with flucytosine, the rate of clinical success at 10 weeks was greater than that previously reported with regard to the use of fluconazole alone or amphotericin B alone. [ABSTRACT FROM PUBLISHER]

Patients with AIDS and Mycobacterium avium complex (MAC) bacteremia are at high risk for relapse and emergence of resistant isolates during monotherapy with clarithromycin. Ninety-five AIDS patients with MAC bacteremia received clarithromycin plus clofazimine, with or without ethambutol, in a prospective, multicenter, randomized open-label trial. Of 80 patients with positive baseline cultures, sterilization or a 2 log10 reduction in colony-forming units of MAC in two consecutive blood cultures occurred in 69% of both groups. There were nine relapses in the two-drug arm and three in the three-drug arm. Kaplan-Meier estimates of risk of relapse at 36 weeks were 68% and 12%, respectively (P = .004). All relapse isolates were resistant to clarithromycin. Median time to clarithromycin resistance was 16 weeks with two drugs and 40 weeks with three drugs (P = .004). Ethambutol reduced relapses and emergence of clarithromycin resistance and should be considered an essential component of clarithromycin-based therapies for MAC bacteremia. [ABSTRACT FROM PUBLISHER]

Urine and blood leukocyte cultures and qualitative plasma polymerase chain reaction (PCR) and quantitative competitive (QC) PCR were evaluated for their ability to identify AIDS patients at risk for human cytomegalovirus (HCMV) disease. AIDS patients were followed with urine and blood specimens every 3 months. During a mean follow-up of 12 months, 26 (28%) developed HCMV disease. The sensitivity, specificity, positive predictive value, and negative predictive value for urine culture were 85%, 29%, 31%, and 83%; for leukocyte culture were 38%, 74%, 69%, and 81%; for qualitative plasma PCR were 89%, 75%, 58%, and 94%; for QC-PCR (> 1000 copies/µL) were 35%, 100%, 100%, and 80%; and for QC-PCR (> 100 copies/µL) were 73%, 90%, 73%, and 90%, respectively. Of 41 patients identified by qualitative PCR to have HCMV DNA in plasma, the 24 who developed HCMV disease had 1510 ± 448 (mean ± SE) peak copies of HCMV DNA/µL by QC-PCR, versus 161 ± 52 for the 17 patients who did not develop disease (P = .0007). Thus, plasma PCR is superior to culture for identification of AIDS patients at risk for HCMV disease, and quantitation of plasma DNA further identifies high-risk persons. [ABSTRACT FROM PUBLISHER]

Eight patients (6, cryptococcal meningitis; 2, high-titer cryptococcal antigenemia) were treated with 800 mg/day fluconazole to assess the safety and efficacy of high-dose fluconazole as primary therapy. Five patients with meningitis had resolution of clinical symptoms and all 6 had negative cerebrospinal fluid (CSF) cultures by day 82 (median, 21 days). One meningitis patient developed neurologic deterioration and was switched to amphotericin B at day 18, but CSF culture was negative on day 15 of fluconazole therapy. In 2 patients with cryptococcal antigenemia, clinical symptoms resolved and serum antigen titers declined rapidly; they did not progress to meningitis. Therapy was well tolerated, with mainly gastrointestinal side effects. Four patients had mild increases in liver enzymes; another had a threefold increase in alkaline phosphatase. Mean steady-state serum level of fluconazole was 45 ± 15 µg/mL, and paired CSF and serum levels were 40 ± 14 and 49 ± 14 µg/mL, respectively. High-dose fluconazole appears safe and effective for cryptococcal disease in AIDS patients. [ABSTRACT FROM PUBLISHER]

The association between isolation of the syncytium-inducing(SI) phenotype of human immunodeficiency virus (HIV) and unfavorable clinical and immune status was evaluated in a crosssectional study. Data on HIV phenotype were available for 341 of 878 persons entering clinical trials of antiretroviral therapies. Patients with SI virus were demographically similar to those with non-SI (NSI) virus but weremore likely to havea diagnosis of AIDS and detectable circulating HIV p24 antigen. Patients with SI virus also had a lower CD4+ cell count and a higher serum level of β2-microglobulin. The association between phenotype and present status was explained statistically by CD4+ cell count. Phenotype, serum level of β2-microglobulin, and the presence of detectable p24 antigen were all independent predictors of present CD4+ cell count. The likelihood of finding SI virus increased with unfavorable virologic and immunologic parameters and varied with the amount of prior antiretroviral therapy. [ABSTRACT FROM PUBLISHER]

A patient with acute cholecystitis due to Candida albicans and Candida parapsilosis was treated with a percutaneous cholecystotomy and daily intravenous fluconazole. Fluconazole levels in serum and bile were measured by gas chromatography. Fluconazole levels in the bile were equal to those in the blood for the first 8 hours after a dose and were slightly higher than serum levels after that. Bile levels after an oral dose of fluconazole were 15% higher than levels achieved after intravenous administration of the drug. The infection was cured after 2 weeks of treatment. This experience suggests that sufficient fluconazole is excreted in the bile to be effective for treatment of biliary infections due to susceptible yeasts. [ABSTRACT FROM PUBLISHER]

The author reflects on the relation between Human Immunodeficiency Virus (HIV) infections and cardiovascular disease. He states that the main cause of death of the patients suffering from HIV infections is cardiovascular disease.The author tells that persons who are infected with HIV have more risk of vascular disease which results in a number of ways. He also comments on various related studies.

In this article, the author reflects on the quality of care for patients infected with human immunodeficiency virus (HIV) in the U.S. He cites the reports of Institute of Medicine "Crossing the Quality Chasm," which emphasizes quality health care, yet studies have shown that care did not meet professional standards which also led to wide calls for quality care for HIV patients. He suggests various system in caring HIV patients including the mobilizations of different organizations.