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ObjectivesTo define the incidence of clinically-detected COVID-19 in people with HIV (PWH) in the US and evaluate how racial and ethnic disparities, comorbidities, and HIV-related factors contribute to risk of COVID-19.DesignObservational study within the CFAR Network of Integrated Clinical Systems cohort in 7 cities during 2020.MethodsWe calculated cumulative incidence rates of COVID-19 diagnosis among PWH in routine care by key characteristics including race/ethnicity, current and lowest CD4 count, and geographic area. We evaluated risk factors for COVID-19 among PWH using relative risk regression models adjusted with disease risk scores.ResultsAmong 16,056 PWH in care, of whom 44.5% were Black, 12.5% were Hispanic, with a median age of 52 years (IQR 40-59), 18% had a current CD4 count < 350, including 7% < 200; 95.5% were on antiretroviral therapy, and 85.6% were virologically suppressed. Overall in 2020, 649 PWH were diagnosed with COVID-19 for a rate of 4.94 cases per 100 person-years. The cumulative incidence of COVID-19 was 2.4-fold and 1.7-fold higher in Hispanic and Black PWH respectively, than non-Hispanic White PWH. In adjusted analyses, factors associated with COVID-19 included female sex, Hispanic or Black identity, lowest historical CD4 count ConclusionsOur results suggest that the presence of structural racial inequities above and beyond medical comorbidities increased the risk of COVID-19 among PWHPWH with immune exhaustion as evidenced by lowest historical CD4 or current low CD4:CD8 ratio had greater risk of COVID-19.

Zidovudine therapy improves survival in advanced human immunodeficiency virus (HIV) infection and delays progression from earlier stages to advanced stage of HIV disease. The duration of the benefit of zidovudine therapy, however, may be limited.To quantitate the duration of the survival benefit of zidovudine therapy in a heterogeneous patient population receiving care for HIV infection in an urban clinic.We analyzed data from 393 HIV-infected patients with CD4+ cell counts of 0.5 x 10(9)/L (500 cells/microliter.) or less who first presented for care at The Johns Hopkins HIV Clinic, Baltimore, Md, from July 1989 through December 1993. Follow-up extended to a maximum of 3 years (median, 2 years). Survival probabilities in patients who received and who did not receive zidovudine therapy were analyzed by Kaplan-Meier methods and by multivariate Cox proportional hazards regression analysis adjusting for both time-dependent and fixed prognostic covariates.Adjusting for baseline differences in CD4+ cell count, clinical stage of HIV disease, and prophylaxis for Pneumocystis carinii pneumonia, Cox regression analysis showed a significant effect of zidovudine compared with no treatment on the risk of dying during the first year of therapy (relative hazard for death, 0.32; 95% confidence interval [CI], 0.18 to 0.59). However, analysis of the time-dependent effect of zidovudine therapy showed that there was a diminishing relative hazard between treatment and no treatment of 0.75 (95% CI, 0.45 to 1.26) at 1 to 2 years of therapy and a relative hazard of 1.61 beyond 2 years (95% CI, 0.70 to 3.71).The survival advantage of zidovudine therapy is time dependent, lasting between 1 and 2 years in patients with CD4+ cell counts of 0.5 x 10(9)/L or less. Alternative antiretroviral treatment may be indicated at that time.

In human immunodeficiency virus (HIV) disease, neutropenia occurs most commonly in patients who are also severely immunosuppressed. It is not currently known whether neutropenia is an independent risk factor for the development of bacterial infection, which is a potentially serious complication of advanced HIV disease.We compared the incidence of bacterial infection between 118 neutropenic patients (absolute neutrophil count [ANC],1 x 10(9)/L) and 118 nonneutropenic patients matched for CD4+ lymphocyte count, use of injecting drugs, and follow-up time from a demographically heterogeneous urban cohort of HIV-infected patients followed up longitudinally at the Johns Hopkins Hospital. The incidence of serious infection was analyzed separately for patients with an ANC of less than 1, less than 0.75, or less than 0.5 x 10(9)/L.There were no statistically significant associations found between neutropenia and several individual bacterial infections, including bacteremia, pneumonia, endocarditis, bacterial enterocolitis, and infection of normally sterile sites for any level of neutropenia. However, for all these infections combined, the adjusted relative risk for the occurrence of bacterial infection was 2.33 (95% confidence interval, 1.00 to 5.40; P = .05) for patients with an ANC of less than 1 x 10(9)/L and 7.92 (95% confidence interval, 1.18 to 53.2; P = .03) for those with an ANC of less than 0.5 x 10(9)/L. The incidence of serious bacterial infection ranged from two to three infections per 100 person-months of neutropenia for patients with an ANC of less than 1 x 10(9)/L and three to five infections per 100 person-months of neutropenia for patients with an ANC of less than 0.5 x 10(9)/L for all bacterial infections combined.Our matched cohort analysis indicates that neutropenia is an independent risk factor for bacterial infection in patients with advanced HIV disease. Given the incidence of infection, the cost-effectiveness of interventions to prevent neutropenia in advanced HIV disease should be assessed.

A direct relationship has been postulated between high "negative" coronary angiogram rates and physician payment. We conducted a prospective study of coronary angiography in a teaching and community hospital staffed, respectively, by cardiologists who were performing cardiac catheterization as salaried or fee-for-service physicians. The lower overall rate of negative angiograms at the teaching hospital correlated with the presence of a cardiac surgery unit and the increased referral of patients with documented coronary artery disease. The percentage of completely normal angiograms did not differ significantly between hospitals. The number of angiograms positive by a 70% occlusion criterion in patients not previously known to have coronary artery disease also did not differ greatly. Negative angiogram rates appeared to vary inversely with physician ability to set preangiogram probabilities of coronary artery disease. Our findings do not discount reimbursement as a strong incentive, but suggest other important determinants of coronary angiographic variation.

To gain insight into diagnostic test use, we interviewed 42 physicians who ordered 62 liver-spleen scans to detect possible metastases. Before receiving the actual scan results, physicians gave (1) pretest probability estimates for liver metastasis; (2) probability estimates and management plans given the most common scan results; and (3) probabilities above and below which they would stop the diagnostic workup (their decision thresholds). After learning the actual scan results, physicians gave their posttest probabilities and management plans. Thirteen physicians (31%) desired absolute certainty to rule in metastasis. Fifty percent planned further evaluations even when probability estimates of metastasis reached one of their probability targets for ending the workup. Greater attention to decision thresholds may improve physicians' understanding of their tolerance for diagnostic uncertainty and the ability of diagnostic tests to reduce it.

We evaluated physicians' perceptions of the performance capabilities of the liver-spleen scan (LSS) in detecting metastases and the inferences physicians draw from LSS results. Physicians' perceptions of the sensitivity and specificity of the LSS in detection of metastases, as well as their estimates of likelihood ratios for various scan results, varied broadly over a range that could result in clinically important variations in patient treatment. In addition, independent of any variations in estimates of test performance characteristics, physicians had difficulty drawing appropriate probabilistic inferences from LSS results. Our findings suggest that data regarding the performance capabilities of the LSS and other diagnostic tests within a particular hospital should be made available to physicians and that physicians should be given microcomputer assistance in estimating the impact of test results on the probability of disease.