Jeanne C Keruly

Johns Hopkins University, Baltimore, Maryland, United States

Are you Jeanne C Keruly?

Claim your profile

Publications (68)551.58 Total impact

  • [Show abstract] [Hide abstract]
    ABSTRACT: Retaining HIV patients in medical care promotes access to antiretroviral therapy, viral load suppression, and reduced HIV transmission to partners. We estimate the programmatic costs of a U.S. multi-site randomized controlled trial of an intervention to retain HIV patients in care. Six academically affiliated HIV clinics randomized patients to intervention (enhanced personal contact with patients across time coupled with basic HIV education) and control (standard of care (SOC)) arms. Retention in care was defined as 4-month visit constancy, i.e., at least one primary care visit in each four-month interval over a 12-month period. We used micro-costing methods to collect unit costs, and measure the quantity of resources used to implement the intervention in each clinic. All fixed and variable labor and non-labor costs of the intervention were included. Visit constancy was achieved by 45.7% (280/613) of patients in the SOC arm, and by 55.8% (343/615) of patients in the intervention arm, representing an increase of 63 patients (relative improvement 22.1%; 95% CI 9%-36%, P < 0.01). The total annual cost of the intervention at the six clinics was $241,565, the average cost per patient $393, and the estimated cost per additional patient retained in care beyond SOC was $3,834. Our analyses showed that a retention in care intervention consisting of enhanced personal contact coupled with basic HIV education may be delivered at fairly low cost. These results provide useful information for guiding decisions about planning or scaling-up retention in care interventions for HIV-infected patients.
    Journal of acquired immune deficiency syndromes (1999). 12/2014;
  • Clinical infectious diseases : an official publication of the Infectious Diseases Society of America. 08/2014;
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Epidemiological evidence suggests that HIV-infected individuals are at increased risk of lung cancer, but no data exist because large computed tomography (CT) screening trials routinely exclude HIV-infected participants. From 2006 to 2013, we conducted the world's first lung cancer screening trial of 224 HIV-infected current/former smokers to assess the CT detection rates of lung cancer. We also used 130 HIV-infected patients with known lung cancer to determine radiographic markers of lung cancer risk using multivariate analysis. Median age was 48 years with 34 pack-years smoked. During 678 person-years, one lung cancer was found on incident screening. Besides this lung cancer case, 18 deaths (8%) occurred, but none were cancer related. There were no interim diagnoses of lung or extrapulmonary cancers. None of the pulmonary nodules detected in 48 participants at baseline were diagnosed as cancer by study end. The heterogeneity of emphysema across the entire lung as measured by CT densitometry was significantly higher in HIV-infected subjects with lung cancer compared with the heterogeneity of emphysema in those without HIV (p ≤ 0.01). On multivariate regression analysis, increased age, higher smoking pack-years, low CD4 nadir, and increased heterogeneity of emphysema on quantitative CT imaging were all significantly associated with lung cancer. Despite a high rate of active smoking among HIV-infected participants, only one lung cancer was detected in 678 patient-years. This was probably because of the young age of participants suggesting that CT screening of high-risk populations should strongly consider advanced age as a critical inclusion criterion. Future screening trials in urban American must also incorporate robust measures to ensure HIV patient compliance, adherence, and smoking cessation.
    Journal of thoracic oncology: official publication of the International Association for the Study of Lung Cancer 06/2014; 9(6):752-9. · 4.55 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Abstract The recommendation for the frequency for routine clinical monitoring of persons with well-controlled HIV infection is based on evidence that relies on observed rather than intended follow-up intervals. We sought to determine if the scheduled follow-up interval is associated with subsequent virologic failure. Participants in this 6-clinic retrospective cohort study had an index clinic visit in 2008 and HIV viral load (VL) ≤400 c/mL. Univariate and multivariate tests evaluated if scheduling the next follow-up appointment at 3, 4, or 6 months predicted VL >400 c/mL at 12 months (VF). Among 2171 participants, 66%, 26%, and 8% were scheduled next follow-up visits at 3, 4, and 6 months, respectively. With missing 12-month VL considered VF, 25%, 25%, and 24% of persons scheduled at 3, 4, and 6 months had VF, respectively (p=0.95). Excluding persons with missing 12-month VL, 7.1%, 5.7%, and 4.5% had VF, respectively (p=0.35). Multivariable models yielded nonsignificant odds of VF by scheduled follow-up interval both when missing 12-month VL were considered VF and when persons with missing 12-month VL were excluded. We conclude that clinicians are able to make safe decisions extending follow-up intervals in persons with viral suppression, at least in the short-term.
    AIDS patient care and STDs 07/2013; · 2.68 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Viral suppression and viral breakthrough impact the humoral immune response to HIV infection. We evaluated the impact of viral suppression and viral breakthrough on results obtained with two cross-sectional HIV incidence assays. All samples were collected from adults in the US who were HIV infected for >2 years. Samples were tested with the BED capture enzyme immunoassay (BED-CEIA) which measures the proportion of IgG that is HIV-specific, and with an antibody avidity assay based on the Genetic Systems 1/2+ O ELISA. We tested 281 samples: (1) 30 samples from 18 patients with natural control of HIV-1 infection known as elite controllers or suppressors (2) 72 samples from 18 adults on antiretroviral therapy (ART), with 1 sample before and 2-6 samples after ART initiation, and (3) 179 samples from 20 virally-suppressed adults who had evidence of viral breakthrough receiving ART (>400 copies/ml HIV RNA) and with subsequent viral suppression. For elite suppressors, 10/18 had BED-CEIA values <0.8 normalized optical density units (OD-n) and these values did not change significantly over time. For patients receiving ART, 14/18 had BED-CEIA values that decreased over time, with a median decrease of 0.42 OD-n (range 0.10 to 0.63)/time point receiving ART. Three patterns of BED-CEIA values were observed during viral breakthrough: (1) values that increased then returned to pre-breakthrough values when viral suppression was re-established, (2) values that increased after viral breakthrough, and (3) values that did not change with viral breakthrough. Viral suppression and viral breakthrough were associated with changes in BED-CEIA values, reflecting changes in the proportion of HIV-specific IgG. These changes can result in misclassification of patients with long-term HIV infection as recently infected using the BED-CEIA, thereby influencing a falsely high value for cross-sectional incidence estimates.
    PLoS ONE 01/2013; 8(2):e55525. · 3.53 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Chronic cocaine use may lead to premature atherosclerosis, but the prevalence of and risk factors for coronary artery disease (CAD) in asymptomatic cocaine users have not been reported. The objective of this study was to examine whether vitamin D deficiency is associated with the development of CAD in human immunodeficiency virus (HIV)-infected African American cocaine users with low CAD risk. In this prospective follow-up study, we investigated 169 HIV-infected African American cocaine users with low Framingham risk at baseline. The main outcome measures were incidence of subclinical CAD and development of subclinical CAD. Fifty of the 169 African Americans had evidence of subclinical disease on the initial cardiac computed tomography. A second cardiac computed tomography was performed on the 119 African Americans without disease on the first scan. The total sum of person-years of follow-up was 289.6. Subclinical CAD was detected in 11 of these, yielding an overall incidence of 3.80/100 person-years (95% confidence interval 1.90-6.80). Among the factors investigated, only vitamin D deficiency was independently associated with development of subclinical CAD. The study did not find significant associations between CD4 count, HIV viral load, or antiretroviral treatment use and the incidence of subclinical CAD. This study appears to suggest that there is a threshold level of vitamin D (10 ng/mL) above which the effect of vitamin D on subclinical CAD is diminished. The incidence of subclinical CAD in HIV-infected African American cocaine users with low CAD risk is high, especially in those with vitamin D deficiency. Well designed randomized clinical trials are warranted to confirm the role of vitamin D deficiency in the development of CAD in HIV-infected African American cocaine users with low CAD risk.
    Vascular Health and Risk Management 01/2013; 9:729-737.
  • [Show abstract] [Hide abstract]
    ABSTRACT: Background: The U.S. Department of Health and Human Services HIV treatment guidelines recommend clinic visits every 3 to 6 months. We sought to determine if extending the follow-up interval beyond every 3 months is associated with an increased risk of virologic failure (>400 copies/ml=VF) at 12 months in routine care. Methods: Clinic-wide patient demographic, laboratory, and primary care appointment data from six academic HIV clinics were examined for this retrospective cohort analysis. Participants had a baseline clinic visit between April and June 2008 and an HIV viral load of ≤400 copies/mL on or 60 days before their baseline visit. Univariate chi-square tests evaluated associations of demographic and lab variables with the next follow-up (3, 4, or 6 months) and with VF at 12 months (missing=failure). Multivariate generalized estimating equations analysis determined factors associated with VF. Results: Among 2,171 patients (70% male, mean age 47 years, 56% black, 49% heterosexual), patients who were scheduled follow-up at 3 months were more likely to be black and have a baseline CD4 count <200 cells/mm3, while patients who were scheduled follow-up at 6 months were more likely to be white, men who have sex with men, have private insurance, and have a baseline CD4 >350 cells/mm3 (p<0.01 for all comparisons); 25% of patients had VF. The odds of VF did not differ with 4-month vs. 3-month scheduled follow-up (OR=1.04, p=0.64) or with 6-month vs. 3-month scheduled follow-up (OR=0.97, p=0.91). Male gender (OR=1.27, p<0.01), CD4 <200 cells/mm3 (OR=1.77, p<0.01), cancelling the follow-up visit (OR=1.60, p<0.01), and missing the follow-up visit (OR=2.92, p<0.01) were independently associated with VF at 12 months. Conclusion: In this observational dataset, clinicians in routine care safely scheduled next follow-up intervals in virologically suppressed patients, as patients with a scheduled visit in 4 or 6 months were not at increased risk of virologic failure at 12 months. Early diagnosis and maximizing appointment adherence are important for virologic suppression.
    IDWeek 2012 Meeting of the Infectious Diseases Society of America; 10/2012
  • Richard D Moore, Jeanne C Keruly, John G Bartlett
    [Show abstract] [Hide abstract]
    ABSTRACT: Background. Despite advances in human immunodeficiency virus (HIV) treatment, major challenges remain in achieving access, retention, and adherence. Our inner-city HIV clinical practice in Baltimore has a diverse patient population with high rates of poverty, black race, and injection drug use (IDU), providing us the opportunity to compare health process and outcomes. Methods. Using data collected in a clinical HIV cohort in Baltimore, we compared receipt of combination antiretroviral therapy (ART), HIV type 1 (HIV-1) RNA, CD4, incidence of opportunistic illness, and mortality from 1995 to 2010. Comparisons were made of these outcomes by HIV risk group, sex, and race (black, white). Results. From 1995 to 2010, we followed 6366 patients comprising 27 941 person-years (PY) of follow-up. By 2010, 87% of patients were receiving ART; median HIV-1 RNA was <200 copies/mL, median CD4 was 475 cells/mm(3), opportunistic illness rates were 2.4 per 100 PY, and mortality rates were 2.1 per 100 PY, with no differences by demographic or HIV risk group. The only differences were that the IDU risk group had a median CD4 that was 79 cells/mm(3) lower and HIV-1 RNA 0.16 log(10 )copies/mL higher compared with other risk groups (P < .01). In 2009 a 28-year-old HIV-infected person was estimated to have 45.4 years of life remaining, which did not differ by demographic or behavioral risk group. Discussion. Our results emphasize that advances in HIV treatment have had a positive impact on all affected demographic and behavioral risk groups in an HIV clinical setting, with an expected longevity for HIV-infected patients that is now 73 years.
    Clinical Infectious Diseases 09/2012; 55(9):1242-51. · 9.37 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: BACKGROUND:: Measuring retention in HIV primary care is complex as care includes multiple visits scheduled at varying intervals over time. We evaluated six commonly used retention measures in predicting viral load (VL) suppression and the correlation among measures. METHODS:: Clinic-wide patient-level data from six academic HIV clinics were used for 12-months preceding implementation of the CDC/HRSA Retention in Care intervention. Six retention measures were calculated for each patient based upon scheduled primary HIV provider visits: count and dichotomous missed visits, visit adherence, 6-month gap, 4-month visit constancy, and the HRSA HAB retention measure. Spearman correlation coefficients and separate unadjusted logistic regression models compared retention measures to one another and with 12-month VL suppression, respectively. The discriminatory capacity of each measure was assessed with the c-statistic. RESULTS:: Among 10,053 patients, 8,235 (82%) had 12-month VL measures, with 6,304 (77%) achieving suppression (VL<400 c/mL). All six retention measures were significantly associated (P<0.0001) with VL suppression (OR;95%CI, c-statistic): missed visit count (0.73;0.71-0.75,0.67), missed visit dichotomous (3.2;2.8-3.6,0.62), visit adherence (3.9;3.5-4.3,0.69), gap (3.0;2.6-3.3,0.61), visit constancy (2.8;2.5-3.0,0.63), HRSA HAB (3.8;3.3-4.4,0.59). Measures incorporating "no show" visits were highly correlated (Spearman coefficient=0.83-0.85), as were measures based solely upon kept visits (Spearman coefficient=0.72-0.77). Correlation coefficients were lower across these two groups of measures (Range=0.16-0.57). CONCLUSIONS:: Six retention measures displayed a wide range of correlation with one another, yet each measure had significant association and modest discrimination for VL suppression. These data suggest there is no clear gold standard, and that selection of a retention measure may be tailored to context.
    JAIDS Journal of Acquired Immune Deficiency Syndromes 09/2012; · 4.65 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: BACKGROUND:: We evaluated the longitudinal association of alcohol use with immunological response to combination antiretroviral therapy (ART) among HIV infected individuals. METHODS:: This was a prospective cohort study of individuals initiating ART. Participants underwent an Audio Computer-Assisted Self Interview querying drug and alcohol use within 6 months of treatment. Immunological response to ART was defined by CD4 T-cell count (CD4). Primary independent variables were self-reported number of drinks consumed per drinking day (quantity) and days of alcohol consumption in a typical week (frequency). We used linear mixed effects models to quantify the association between CD4 T-cell count and alcohol quantity and frequency and Cox proportional hazards models to estimate the relative hazard of an increase 100, 150 and 200 CD4 cells/mm per additional drink per drinking day. Analyses were stratified by gender. Viral suppression was examined as a time-varying covariate. RESULTS:: Between 2000-2008, 1107 individuals were eligible for inclusion in this study. There was no statistically significant difference in CD4 T-cell count by average drinks per drinking day at any frequency of alcohol use irrespective of gender or viral suppression. Similarly, we found no difference in the hazard ratio for drinks per drinking day within the categories of drinking frequency for time to CD4 T-cell count increase of 100, 150 and 200 cells/mm, respectively. CONCLUSIONS:: Among individuals initiating antiretroviral therapy (ART) the benefits of therapy and viral suppression on the immune system outweigh detrimental effects of alcohol, reinforcing the importance of initiating ART and ensuring adequate adherence to therapy.
    JAIDS Journal of Acquired Immune Deficiency Syndromes 09/2012; · 4.65 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Background. Retention in care for human immunodeficiency virus (HIV)-infected patients is a National HIV/AIDS Strategy priority. We hypothesized that retention could be improved with coordinated messages to encourage patients' clinic attendance. We report here the results of the first phase of the Centers for Disease Control and Prevention/Health Resources and Services Administration Retention in Care project. Methods. Six HIV-specialty clinics participated in a cross-sectionally sampled pretest-posttest evaluation of brochures, posters, and messages that conveyed the importance of regular clinic attendance. 10 018 patients in 2008-2009 (preintervention period) and 11 039 patients in 2009-2010 (intervention period) were followed up for clinic attendance. Outcome variables were the percentage of patients who kept 2 consecutive primary care visits and the mean proportion of all primary care visits kept. Stratification variables were: new, reengaging, and active patients, HIV RNA viral load, CD4 cell count, age, sex, race or ethnicity, risk group, number of scheduled visits, and clinic site. Data were analyzed by multivariable log-binomial and linear models using generalized estimation equation methods. Results. Clinic attendance for primary care was significantly higher in the intervention versus preintervention year. Overall relative improvement was 7.0% for keeping 2 consecutive visits and 3.0% for the mean proportion of all visits kept (P < .0001). Larger relative improvement for both outcomes was observed for new or reengaging patients, young patients and patients with elevated viral loads. Improved attendance among the new or reengaging patients was consistent across the 6 clinics, and less consistent across clinics for active patients. Conclusion. Targeted messages on staying in care, which were delivered at minimal effort and cost, improved clinic attendance, especially for new or reengaging patients, young patients, and those with elevated viral loads.
    Clinical Infectious Diseases 07/2012; 55(8):1124-1134. · 9.37 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: The purpose of this study was to assess the effect of human immunodeficiency virus (HIV) infection on postoperative survival among non-small cell lung cancer (NSCLC) patients. A retrospective cohort study compared 22 HIV-infected lung cancer patients to 2,430 lung cancer patients with HIV-unspecified status who underwent resection at Johns Hopkins Hospital from 1985 to 2009. Subcohort comparative analyses were performed using individual matching methods. Thirty-day mortality rates did not differ between HIV-infected and HIV-unspecified patients. Survival rates for HIV-infected lung cancer patients were significantly shorter than for HIV-unspecified patients (median, 26 versus 48 months; p=0.001). After adjustment, the relative hazard of mortality among HIV-infected NSCLC patients was more than threefold that of HIV-unspecified patients (adjusted hazard ratio, 3.08; 95% confidence interval: 1.85 to 5.13). When additional surgical characteristics were modeled in a matched subcohort, the association remained statistically significant (adjusted hazard ratio, 2.31; 95% confidence interval: 1.11 to 4.81). Moreover, HIV-infected lung cancer patients with CD4 counts less than 200 cells/mm3 had shortened median survival compared with patients whose CD4 counts were 200 cells/mm3 or greater (8 versus 40 months; p=0.031). Postoperative pulmonary and infectious complications were also elevated in the HIV-infected group (p=0.001 and p<0.001, respectively). After surgery, median time to cancer progression was shorter among HIV-infected patients (20.4 months) versus HIV-unspecified patients (p=0.061). The HIV-infected NSCLC patients have more postoperative complications, rapid progression to disease recurrence, and poorer postoperative survival. Optimizing immune status before surgery and careful patient selection based on diffusion capacity of lung for carbon monoxide may improve patient outcomes.
    The Annals of thoracic surgery 02/2012; 93(2):405-12. · 3.45 Impact Factor
  • Clinical Infectious Diseases 12/2011; 53(11):1168-9; author's reply 1169-70. · 9.37 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Late presentation to HIV clinical care increases individual risk for (multiple) clinical events and death, and decreases successful response to highly active antiretroviral therapy (HAART). In Brazil, provision of HAART free of charge to all individuals infected with HIV could lead to increased testing and linkage to care. We assessed the immune status of 2555 patients who newly presented for HIV clinical care between 1997 and 2009 at the Johns Hopkins Clinical Cohort, in Baltimore, Md, and at the Instituto de Pesquisa Clinica Evandro Chagas Clinical Cohort, in Rio de Janeiro, Brazil. The mean change in the CD4 cell count per year was estimated using multivariate linear regression models. Overall, from 1997 to 2009, 56% and 54% of the patients presented for HIV clinical care with CD4 count ≤350 cells per cubic millimeter in Baltimore and Rio de Janeiro, respectively. On average, 75% of the patients presented with viral load >10,000 copies per millimeter. In Rio de Janeiro only, the overall adjusted per year increase in the mean CD4 cell count was statistically significant (5 cells/mm, 95% confidence interval: 1 to 10 cells/mm). We found that, over years, the majority of patients presented late, that is, with a CD4 count <350 cells per cubic millimeter. Our findings indicate that, despite the availability of HAART for more than a decade, and mass media campaigns stimulating HIV testing in both countries, the proportion of patients who start therapy at an advanced stage of the disease is still high.
    JAIDS Journal of Acquired Immune Deficiency Syndromes 08/2011; 57 Suppl 3:S171-8. · 4.65 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Studies on the long-term safety and tolerability of HAART are scarce in developing countries. HAART has been universally available in Brazil since 1997, providing a unique opportunity to evaluate the incidence and risk factors for HAART discontinuation or modification. We analyzed retrospective data from 670 treatment-naive patients followed at the HIV cohort of Evandro Chagas Clinical Research Institute, Oswaldo Cruz Foundation, in Rio de Janeiro, Brazil, who first received HAART between January 1996 and December 2006. Our four outcomes of interest were treatment failure (TF-MOD), short-term toxicity (ST-MOD), long-term toxicity (LT-MOD), and overall modification/discontinuation (MOD, composed of TF-MOD, ST-MOD, LT-MOD, and other reasons). Risk factors were assessed using Cox's proportional hazards regression. Incidences of MOD, ST-MOD, LT-MOD, and TF-MOD were 28.3, 24.0, 4.0, and 5.6 per 100 persons-years, respectively. MOD was observed in 69% of the patients; 40% of the MODs were toxicity related. The risk of MOD in the first year of treatment was 32% (95% CI: 28.3-35.5%); the median time from HAART initiation to MOD was 14 months (IQR: 3.0-29.5). The most frequent reasons for ST-MOD were gastrointestinal; women had a higher hazard for ST-MOD. Metabolic toxicity was the most frequent reason for LT- MOD, particularly dislipidemia and lipodystrophy. Increased hazard of TF-MOD was observed among those with lower CD4(+) lymphocyte counts (<200 cells/mm(3)). Our results indicate that toxicities can compromise adherence and thus impact future treatment options. This is especially relevant in the context of limited access to second and third line treatment regimens.
    AIDS research and human retroviruses 08/2010; 26(8):865-74. · 2.18 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Opioid dependence is common in HIV clinics. Buprenorphine-naloxone (BUP) is an effective treatment of opioid dependence that may be used in routine medical settings. To compare clinic-based treatment with BUP (clinic-based BUP) with case management and referral to an opioid treatment program (referred treatment). Single-center, 12-month randomized trial. Participants and investigators were aware of treatment assignments. (ClinicalTrials.gov registration number: NCT00130819) HIV clinic in Baltimore, Maryland. 93 HIV-infected, opioid-dependent participants who were not receiving opioid agonist therapy and were not dependent on alcohol or benzodiazepines. Clinic-based BUP included BUP induction and dose titration, urine drug testing, and individual counseling. Referred treatment included case management and referral to an opioid-treatment program. Initiation and long-term receipt of opioid agonist therapy, urine drug test results, visit attendance with primary HIV care providers, use of antiretroviral therapy, and changes in HIV RNA levels and CD4 cell counts. The average estimated participation in opioid agonist therapy was 74% (95% CI, 61% to 84%) for clinic-based BUP and 41% (CI, 29% to 53%) for referred treatment (P < 0.001). Positive test results for opioids and cocaine were significantly less frequent in clinic-based BUP than in referred treatment, and study participants receiving clinic-based BUP attended significantly more HIV primary care visits than those receiving referred treatment. Use of antiretroviral therapy and changes in HIV RNA levels and CD4 cell counts did not differ between the 2 groups. This was a small single-center study, follow-up was only moderate, and the study groups were unbalanced in terms of recent drug injections at baseline. Management of HIV-infected, opioid-dependent patients with a clinic-based BUP strategy facilitates access to opioid agonist therapy and improves outcomes of substance abuse treatment. Health Resources and Services Administration Special Projects of National Significance program.
    Annals of internal medicine 06/2010; 152(11):704-11. · 13.98 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Significant hurdles remain to large-scale implementation of medical interventions in the developing world due to the lack of a modern diagnostic infrastructure. This is especially pertinent to the international roll-out of antiretroviral drugs to treat HIV, which ideally includes a CD4 T-cell count to determine eligibility. We designed a novel technique to estimate mature T-cell numbers by calculating the amount of rearranged T-cell receptor β genes from dried blood spots of HIV-infected individuals in the United States and Uganda. It was observed that the rearranged T-cell receptor β count correlated well with total lymphocyte counts from both study populations (Baltimore R=0.602, Uganda R=0.497; p
    Journal of immunological methods 01/2010; 354(1):40-44. · 2.35 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: To compare the early mortality pattern and causes of death among patients starting HAART in Brazil and the United States. We analyzed the combined data from two clinical cohorts followed at the Johns Hopkins AIDS Service in Baltimore, United States, and the Evandro Chagas Clinical Research Institute AIDS Clinic in Rio de Janeiro, Brazil. Participants included those who entered either cohort between 1999 and 2007 and were antiretroviral naive. Follow-up was at 1 year since HAART initiation. Cox proportional hazards regression analysis was used to assess the role of the city on the risk of death. A total of 859 and 915 participants from Baltimore and Rio de Janeiro, respectively, were included. In Rio de Janeiro, 64.7% of deaths occurred within 90 days of HAART initiation; in Baltimore, 48.9% occurred between 180 and 365 days. AIDS-defining illness (61.8%) and non-AIDS-defining illness (55.6%) predominated as causes of death in Rio de Janeiro and Baltimore, respectively. Risk of death was similar in both cities (hazard ratio 1.04; P value = 0.95) after adjusting for CD4 T cell count, age, sex, HIV risk group, prior AIDS-defining illness, and Pneumocystis jirovecii pneumonia and Mycobacterium avium prophylaxis. Individuals with CD4 T cell count less than or equal to 50 cells/microl (hazard ratio 4.36; P = 0.001) or older (hazard ratio, 1.03; P = 0.03) were more likely to die. Although late HIV diagnosis is a problem both in developed and developing countries, differences in the timing and causes of deaths clearly indicate that, besides interventions for early HIV diagnosis, different strategies to curb early mortality need to be tailored in each country.
    AIDS (London, England) 09/2009; 23(16):2107-14. · 4.91 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: The prevalence of HIV infection in older patients (> or =50 years) is increasing due to HAART, and new HIV infections in older patients. Some earlier studies suggest that older patients respond differently to HAART than younger patients. The objective of this study is to compare the effectiveness of HAART in older and younger HIV patients. Retrospective analysis of an observational clinical cohort. Virologic and immunologic response, progression to AIDS and mortality were compared between 670 younger patients (<40 years) and 149 older patients (> or =50 years) by t-test, Kaplan-Meier methods, and multivariate Cox proportional hazards analysis. Compared with younger patients, older patients were more likely to be on nonnucleoside reverse transcriptase inhibitors based versus protease inhibitor based regimens (42 vs. 29%, P < 0.01). Time to HIV-1 RNA virologic suppression was less in older than in younger patients (3.2 vs. 4.4 months, P < 0.01). Immunologic response did not differ by age. Older patients had fewer AIDS-defining opportunistic infections (22 vs. 31%, P < 0.01), but higher mortality (36 vs. 27%, P = 0.04) and shorter survival (25th percentile survivor function 36.2 vs. 58.5 months, P = 0.02) than younger patients. Older age was associated with more rapid virologic suppression [adjusted hazard ratio = 1.33 (1.09-1.63)] and earlier mortality [adjusted hazard ratio = 1.56 (1.14-2.14)]. Nonnucleoside reverse transcriptase inhibitors based regimens were associated with more rapid virologic suppression [adjusted hazard ratio = 1.22 (1.03-1.44)]. Time to virologic suppression after HAART initiation was shorter in older patients, although CD4 response did not differ by age. Older patients had fewer opportunistic infections, but survival was shorter. Our data suggest a need to better understand causes of mortality in older patients.
    AIDS (London, England) 11/2008; 22(17):2331-9. · 4.91 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: 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.
    Clinical Infectious Diseases 10/2008; 47(8):1102-4. · 9.37 Impact Factor

Publication Stats

3k Citations
551.58 Total Impact Points

Institutions

  • 1991–2014
    • Johns Hopkins University
      • • Department of Medicine
      • • Division of Infectious Diseases
      Baltimore, Maryland, United States
  • 2013
    • Baylor College of Medicine
      Houston, Texas, United States
  • 2012
    • Centers for Disease Control and Prevention
      • Division of HIV/AIDS Prevention, Intervention and Support
      Druid Hills, GA, United States
  • 2007–2011
    • Instituto Evandro Chagas
      • Laboratório de Pesquisa Clínica em DST/Aids
      Ananindeua, Pará, Brazil
  • 2009
    • Fundação Oswaldo Cruz
      • National Institute of Infectology (IPEC)
      Rio de Janeiro, Rio de Janeiro, Brazil
  • 2000–2008
    • Johns Hopkins Medicine
      • Division of Infectious Diseases
      Baltimore, Maryland, United States