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Abstract Background Although highly active antiretroviral therapy (HAART) has improved HIV survival, some patients receiving therapy are still dying. This analysis was conducted to identify factors associated with increased risk of post-HAART mortality. Methods We evaluated baseline (prior to HAART initiation) clinical, demographic and laboratory factors (including CD4+ count and HIV RNA level) for associations with subsequent mortality in 1,600 patients who began HAART in a prospective observational cohort of HIV-infected U.S. military personnel. Results Cumulative mortality was 5%, 10% and 18% at 4, 8 and 12 years post-HAART. Mortality was highest (6.23 deaths/100 person-years [PY]) in those with ≤ 50 CD4+ cells/mm3 before HAART initiation, and became progressively lower as CD4+ counts increased (0.70/100 PY with ≥ 500 CD4+ cells/mm3). In multivariate analysis, factors significantly (p < 0.05) associated with post-HAART mortality included: increasing age among those ≥ 40 years (Hazard ratio [HR] = 1.32 per 5 year increase), clinical AIDS events before HAART (HR = 1.93), ≤ 50 CD4+ cells/mm3 (vs. CD4+ ≥ 500, HR = 2.97), greater HIV RNA level (HR = 1.36 per one log10 increase), hepatitis C antibody or chronic hepatitis B (HR = 1.96), and HIV diagnosis before 1996 (HR = 2.44). Baseline CD4+ = 51-200 cells (HR = 1.74, p = 0.06), and hemoglobin < 12 gm/dL for women or < 13.5 for men (HR = 1.36, p = 0.07) were borderline significant. Conclusions Although treatment has improved HIV survival, defining those at greatest risk for death after HAART initiation, including demographic, clinical and laboratory correlates of poorer prognoses, can help identify a subset of patients for whom more intensive monitoring, counseling, and care interventions may improve clinical outcomes and post-HAART survival.

Abstract Background Among HIV-infected persons initiating highly active antiretroviral therapy (HAART), early CD4+ lymphocyte count increases are well described. However, whether CD4+ levels continue to increase or plateau after 4-6 years is controversial. Methods To address this question and identify other determinants of CD4+ response, we analyzed data for 1,846 persons from a prospective HIV military cohort study who initiated HAART, who had post-HAART CD4+ measurements, and for whom HIV seroconversion (SC) date was estimated. Results CD4+ count at HAART initiation was ≤ 200 cells/mm3 for 23%, 201-349 for 31%, 350-499 for 27%, and ≥500 for 19%. The first 6 months post-HAART, the greatest CD4+ increases (93-151 cells) occurred, with lesser increases (22-36 cells/year) through the first four years. Although CD4+ changes for the entire cohort were relatively flat thereafter, HIV viral load (VL) suppressors showed continued increases of 12-16 cells/year. In multivariate analysis adjusting for baseline CD4+ and post-HAART time interval, CD4+ responses were poorer in those with: longer time from HIV SC to HAART start, lower pre-HAART CD4+ nadir, higher pre-HAART VL, and clinical AIDS before HAART (P < 0.05). Conclusions Small but positive long-term increases in CD4+ count in virally suppressed patients were observed. CD4+ response to HAART is influenced by multiple factors including duration of preceding HIV infection, and optimized if treatment is started with virally suppressive therapy as early as possible.

Coccidioidomycosis is an endemic mycosis caused by inhalation of Coccidioides immitis or C. posadasii spores (1). Severe disease is infrequent, and extrapulmonary dissemination occurs in only 1% of diagnosed cases [...]

Objective: Neurocognitive impairment (NCI) is a well-known complication of human immunodeficiency virus (HIV) infection and may be influenced by a number of psychological factors. We examined the relationship between NCI and mental health disorders, including posttraumatic stress disorder (PTSD), in a cohort of 189 active-duty and retired U.S. military men living with HIV. Methods: Participants completed selected modules of the Composite International Diagnostic Interview (CIDI) to ascertain the presence of PTSD, major depressive disorder, and other mental health diagnoses. We also obtained demographic data, including history of head trauma, via personal interview. NCI was assessed with a comprehensive battery of standardized neuropsychological tests. Results: The median age of study subjects was 36 years (interquartile range [IQR] 28 to 43) and median total years of education was 14 (IQR 12 to 16). NCI was diagnosed in 19% of subjects. Individuals with and without a history of PTSD were similar with respect to most HIV-related characteristics; however, the former were significantly more likely to have a prior acquired immunodeficiency syndrome (AIDS) diagnosis. In multivariate analysis, lifetime history of PTSD was independently associated with NCI (odds ration [OR] = 6.12; 95% confidence interval [CI] = 1.85, 20.27), while a history of head of trauma was negatively associated (OR = 0.37 95% CI = 0.15,0.92). Conclusions: Our findings demonstrate that PTSD is an important predictor of NCI in this U.S. military cohort. HIV-infected individuals with cognitive difficulties should be screened for mental health disorders, including PTSD, and prospective studies of the longitudinal relationship between PTSD and NCI, as well as the impact of PTSD treatment on future NCI, are warranted.

ObjectiveTo describe the prevalence of neurocognitive impairment (NCI) among early diagnosed and managed HIV-infected persons (HIV+) compared to HIV-negative controls.MethodsWe performed a cross-sectional study among 200 HIV+ and 50 matched HIV-uninfected (HIV-) military beneficiaries. HIV+ patients were categorized as earlier (200 cells/mm(3)) or later stage patients (n = 100 in each group); both groups were diagnosed early and had access to care. NCI was diagnosed using a comprehensive battery of standardized neuropsychological tests.ResultsHIV+ patients had a median age of 36 years, 91% were seroconverters (median window of 1.2 years), had a median duration of HIV of 5 years, had a CD4 nadir of 319, had current CD4 of 546 cells/mm(3), and 64% were on highly active antiretroviral therapy (initiated 1.3 years after diagnosis at a median CD4 of 333 cells/mm(3)). NCI was diagnosed among 38 (19%, 95% confidence interval 14%-25%) HIV+ patients, with a similar prevalence of NCI among earlier and later stage patients (18% vs 20%, p = 0.72). The prevalence of NCI among HIV+ patients was similar to HIV- patients.ConclusionsHIV+ patients diagnosed and managed early during the course of HIV infection had a low prevalence of NCI, comparable to matched HIV-uninfected persons. Early recognition and management of HIV infection may be important in limiting neurocognitive impairment.

BackgroundSleep disturbances are reportedly common among persons infected with human immunodeficiency virus (HIV), but recent data, including comparisons with HIV-uninfected persons, are limited.MethodsWe performed a cross-sectional study among early-treated HIV-infected military beneficiaries (n = 193) to determine the prevalence and factors associated with insomnia (Pittsburgh Sleep Quality Index [PSQI]) and daytime sleepiness (Epworth Sleepiness Scale [ESS]). Data were compared with HIV-uninfected persons (n = 50) matched by age, sex, race or ethnicity, and military rank.ResultsForty-six percent of HIV-infected persons had insomnia (PSQI >5), and 30% reported daytime drowsiness (ESS ≥10). The prevalence of insomnia and daytime sleepiness was not significantly higher compared with the HIV-uninfected group (38% [P = .30] and 20% [P = .18], respectively). In the multivariate model, factors associated with insomnia among HIV infected patients included depression (odds ratio [OR], 16.8; 95% confidence interval [CI], 2.0-142.1; P = .01), increased waist size (OR, 2.7; 95% CI, 1.4-5.1; P = .002), and fewer years of education (OR, 0.8; 95% CI, .7-.95; P = .006). Neurocognitive impairment (diagnosed in 19% of HIV-infected participants) was not associated with insomnia; however, HIV-infected persons with insomnia were 3.1-fold more likely to have a decline in activities of daily living than those without insomnia (23% vs 9%; P = .01). Only 18% of HIV-infected persons reported using a sleep medication at least weekly.ConclusionsHIV-infected persons have a high prevalence of insomnia, but among an early-treated cohort this rate was not significantly higher compared with HIV-uninfected persons. Factors associated with insomnia among HIV-infected patients include depression and increased waist size. Prompt diagnosis and treatment of sleep disturbances are advocated and may improve quality of life.

Among immunosuppressed persons in industrialized countries, hepatitis E virus (HEV) is a cause of sporadic acute viral hepatitis and chronic hepatitis (1,2). In the United States, liver test results are [...]

We conducted a retrospective cohort study that tested 2,000 US military personnel for Coccidioides antibodies in a disease-endemic region. The overall incidence of seroconversion was 0.5 cases/100 person-years; 12.5% of persons who seroconverted had illnesses requiring medical care. No significant association was found between demographic characteristics and seroconversion or disease. [ABSTRACT FROM AUTHOR]

Venous thrombotic events (VTEs) may occur at higher rates among patients with HIV; some studies suggest that highly active antiretroviral therapy (HAART) may increase the risk for these potentially life-threatening events. We performed a retrospective study among patients with HIV to evaluate the incidence and risk factors for VTEs during the HAART era. A literature review was performed examining VTEs in the pre- and post-HAART eras. Seventeen (3.7%) of 465 patients with HIV experienced a VTE. The overall incidence rate of deep VTEs among HIV-positive persons was 377 cases per 100,000 person-years, a fourfold higher rate compared to age-matched males in the general population. The median age at VTE was 36 years (range, 27-68). Patients with a thrombosis compared to those without had significantly lower current CD4 (153 versus 520 cells/[mm.sup.3], p < 0.001) and nadir (76 versus 276 cells/[mm.sup.3], p < 0.001) CD4 counts, higher viral loads (3.6 versus 1.7 [log.sub.10] copiesper milliliter, p = 0.003), and more likely to have a diagnosis of AIDS (76% versus 32%, p < 0.001); there were no differences in demographics, hyperlipidemia, current use of HAART, the duration of HAART or protease inhibitor (PI) exposure. A review of the literature noted 129 VTE cases; mean age was 40 years, mean CD4 count was 181 cells/[mm.sup.3], the majority of patients were not receiving HAART, and the most common risk factor was an ongoing infection. Thrombotic events are occurring among patients with HIV despite their relatively young ages. Advanced HIV disease is a risk factor for development of thromboses, possibly due to an increased inflammatory state or the presence of concurrent comorbidities such as infections. HAART or PI therapy does not appear to play a significant role in the occurrence of VTEs.

Erectile dysfunction (ED) and hypogonadism are increasingly recognized conditions, however, the prevalence and etiologies of these conditions among HIV-infected men remain unclear. We studied 300 HIV-infected men who completed standardized questionnaires regarding sexual function and hypogonadal symptoms. An early morning testosterone test was performed; patients with a low serum testosterone level (defined by