Predictors of Missed Hepatitis C Intake Appointments and Failure to Establish Hepatitis C Care Among Patients Living With HIV.

BackgroundWe estimated and characterized the proportion of patients living with HIV (PLWH) who missed hepatitis C (HCV) intake appointments and subsequently failed to establish HCV care.MethodsLogistic regression analyses were used to identify factors associated with missed HCV intake appointments and failure to establish HCV care among PLWH referred for HCV treatment between January 2014 and December 2017. In addition to demographics, variables included HIV treatment characteristics, type of insurance, liver health status, active alcohol or illicit drug use, unstable housing, and history of a mental health disorder (MHD).ResultsDuring the study period, 349 new HCV clinic appointments were scheduled for 202 unduplicated patients. Approximately half were nonwhite, and 80% had an undetectable HIV viral load. Drug use (31.7%), heavy alcohol use (32.8%), and MHD (37.8%) were prevalent. Over the 4-year period, 21.9% of PLWH referred for HCV treatment missed their HCV intake appointment. The proportion increased each year, from 17.2% in 2014 to 25.4% in 2017 (P = .021). Sixty-six of the 202 newly referred HCV patients (32.7%) missed their first HCV appointment, and 28 of these (42.4%) failed to establish HCV care. Having a history of MHD, CD4 <200, ongoing drug use, and being nonwhite were independent predictors of missing an intake HCV appointment. The strongest predictor of failure to establish HCV care was having a detectable HIV viral load.ConclusionsThe proportion of PLWH with missed HCV appointments increased over time. HCV elimination among PLWH may require integrated treatment of MHD and substance use

Body image in women with HIV: a cross-sectional evaluation

BACKGROUND: HIV lipodystrophy syndrome is a recognized complication of potent antiretroviral therapy and is characterized by often dramatic changes in various body fat stores, both central and peripheral. Given prior findings of heightened body image dysphoria among HIV-infected men with lipodystrophy as compared to HIV-infected men without lipodystrophy, we sought to determine body image among HIV-infected and HIV-negative women and to determine the relationship of HIV and lipodystrophy with body image. Our a priori hypothesis was that women with HIV and lipodystrophy would have significantly poorer body image as compared to women without HIV and to women with HIV without lipodystrophy. RESULTS: 116 women responded to two previously validated self-report instruments (Body Image Quality of Life Index (BIQLI) and the Situational Inventory of Body-Image Dysphoria – Short Form (SIBID-S)) on body image. 62 (53% subjects) HIV-infected women were recruited at the university-based HIV clinic. 54 (47% subjects) HIV-negative female controls were recruited from another study evaluating bone density in otherwise healthy controls. 96% identified their sexual orientation as women having sex with men. Among the HIV-infected group, 36 reported the presence of lipodystrophic characteristics and 26 reported no lipodystrophic changes. Agreement regarding the presence of lipodystrophy between physician and subject was 0.67 as measured by the kappa coefficient of agreement. Compared to HIV-negative women, HIV-positive women demonstrated poor body image as measured by BIQLI (p = 0.0009). Compared with HIV-infected women who denied lipodystrophy, HIV-infected women with self-reported lipodystrophy demonstrated poor body image as measured by BIQLI (p = 0.02) and SIBID-S scales (p = 0.001). CONCLUSION: We demonstrate that HIV and lipodystrophy status among women is associated with poor body image. Universal efforts should be made in the HIV medical community to recognize body image issues particularly among persons affected by lipodystrophy so that appropriate intervention and support may be provided

An Illustration of Inverse Probability Weighting to Estimate Policy-Relevant Causal Effects

Traditional epidemiologic approaches allow us to compare counterfactual outcomes under 2 exposure distributions, usually 100% exposed and 100% unexposed. However, to estimate the population health effect of a proposed intervention, one may wish to compare factual outcomes under the observed exposure distribution to counterfactual outcomes under the exposure distribution produced by an intervention. Here, we used inverse probability weights to compare the 5-year mortality risk under observed antiretroviral therapy treatment plans to the 5-year mortality risk that would had been observed under an intervention in which all patients initiated therapy immediately upon entry into care among patients positive for human immunodeficiency virus in the US Centers for AIDS Research Network of Integrated Clinical Systems multisite cohort study between 1998 and 2013. Therapy-naïve patients (n = 14,700) were followed from entry into care until death, loss to follow-up, or censoring at 5 years or on December 31, 2013. The 5-year cumulative incidence of mortality was 11.65% under observed treatment plans and 10.10% under the intervention, yielding a risk difference of −1.57% (95% confidence interval: −3.08, −0.06). Comparing outcomes under the intervention with outcomes under observed treatment plans provides meaningful information about the potential consequences of new US guidelines to treat all patients with human immunodeficiency virus regardless of CD4 cell count under actual clinical conditions

Association Between Chronic Hepatitis C Virus Infection and Myocardial Infarction Among People Living With HIV in the United States.

Hepatitis C virus (HCV) infection is common among people living with human immunodeficiency virus (PLWH). Extrahepatic manifestations of HCV, including myocardial infarction (MI), are a topic of active research. MI is classified into types, predominantly atheroembolic type 1 MI (T1MI) and supply-demand mismatch type 2 MI (T2MI). We examined the association between HCV and MI among patients in the Centers for AIDS Research (CFAR) Network of Integrated Clinical Systems, a US multicenter clinical cohort of PLWH. MIs were centrally adjudicated and categorized by type using the Third Universal Definition of Myocardial Infarction. We estimated the association between chronic HCV (RNA+) and time to MI while adjusting for demographic characteristics, cardiovascular risk factors, clinical characteristics, and history of injecting drug use. Among 23,407 PLWH aged ≥18 years, there were 336 T1MIs and 330 T2MIs during a median of 4.7 years of follow-up between 1998 and 2016. HCV was associated with a 46% greater risk of T2MI (adjusted hazard ratio (aHR) = 1.46, 95% confidence interval (CI): 1.09, 1.97) but not T1MI (aHR = 0.87, 95% CI: 0.58, 1.29). In an exploratory cause-specific analysis of T2MI, HCV was associated with a 2-fold greater risk of T2MI attributed to sepsis (aHR = 2.01, 95% CI: 1.25, 3.24). Extrahepatic manifestations of HCV in this high-risk population are an important area for continued research

Transmitted Drug Resistance in the CFAR Network of Integrated Clinical Systems Cohort: Prevalence and Effects on Pre-Therapy CD4 and Viral Load

Human immunodeficiency virus type 1 (HIV-1) genomes often carry one or more mutations associated with drug resistance upon transmission into a therapy-naïve individual. We assessed the prevalence and clinical significance of transmitted drug resistance (TDR) in chronically-infected therapy-naïve patients enrolled in a multi-center cohort in North America. Pre-therapy clinical significance was quantified by plasma viral load (pVL) and CD4+ cell count (CD4) at baseline. Naïve bulk sequences of HIV-1 protease and reverse transcriptase (RT) were screened for resistance mutations as defined by the World Health Organization surveillance list. The overall prevalence of TDR was 14.2%. We used a Bayesian network to identify co-transmission of TDR mutations in clusters associated with specific drugs or drug classes. Aggregate effects of mutations by drug class were estimated by fitting linear models of pVL and CD4 on weighted sums over TDR mutations according to the Stanford HIV Database algorithm. Transmitted resistance to both classes of reverse transcriptase inhibitors was significantly associated with lower CD4, but had opposing effects on pVL. In contrast, position-specific analyses of TDR mutations revealed substantial effects on CD4 and pVL at several residue positions that were being masked in the aggregate analyses, and significant interaction effects as well. Residue positions in RT with predominant effects on CD4 or pVL (D67 and M184) were re-evaluated in causal models using an inverse probability-weighting scheme to address the problem of confounding by other mutations and demographic or risk factors. We found that causal effect estimates of mutations M184V/I ( pVL) and D67N/G ( and pVL) were compensated by K103N/S and K219Q/E/N/R. As TDR becomes an increasing dilemma in this modern era of highly-active antiretroviral therapy, these results have immediate significance for the clinical management of HIV-1 infections and our understanding of the ongoing adaptation of HIV-1 to human populations

Outcomes of pharmacist-assisted management of antiretroviral therapy in patients with HIV infection: A risk-adjusted analysis

The impact of pharmacist-assisted management (PAM) of pharmacotherapy for patients with human immunodeficiency virus (HIV) infection was investigated