Jeanne C Keruly

Johns Hopkins University, Baltimore, Maryland, United States

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Publications (75)638.39 Total impact

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    ABSTRACT: Panic symptoms are prevalent among PLWHAs, yet few studies have examined their relationship with HIV outcomes. Using data from an observational cohort study in Baltimore, MD, we examined the association between panic symptoms and antiretroviral therapy (ART) use, medication adherence, and viral suppression. Data were analyzed using generalized estimating equations and adjusted for age, sex, race/ethnicity, cocaine and/or heroin use, clinic enrollment time, alcohol use, and depressive symptoms. Between June 2010 and September 2012, 1195 individuals participated in 2080 audio computer assisted interviews; 9.9 % (n = 118) of individuals endorsed current panic symptoms. In multivariate analysis, panic symptoms were associated with decreased ART use (IRR 0.94; p = 0.05). Panic symptoms were neither associated with medication adherence nor viral suppression. These findings were independent of depressive symptoms and substance use. Panic symptoms are under-recognized in primary care settings and present an important barrier to ART use. Further studies investigating the reasons for this association are needed.
    AIDS and Behavior 04/2015; DOI:10.1007/s10461-015-1064-4 · 3.49 Impact Factor
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    ABSTRACT: We calculated the financial impact in six HIV clinics of a low-effort retention in care intervention involving brief motivational messages from providers, patient brochures, and posters. We used a linear regression model to calculate absolute changes in kept primary care visits from the pre-intervention year (2008-2009) to the intervention year (2009-2010).Revenue from patients' insurance was also assessed by clinic. Kept visits improved significantly in the intervention year vs. the pre-intervention year (p<0.0001).We found a net-positive effect on clinic revenue of +$24,000/year for an average-size clinic (7,400 scheduled visits/year). We encourage HIV clinic administrators to consider implementing this low-effort intervention.
    JAIDS Journal of Acquired Immune Deficiency Syndromes 12/2014; 68(4). DOI:10.1097/QAI.0000000000000493 · 4.39 Impact Factor
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    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.
    JAIDS Journal of Acquired Immune Deficiency Syndromes 12/2014; 68(3). DOI:10.1097/QAI.0000000000000462 · 4.39 Impact Factor
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    ABSTRACT: Background. The aim of the study was to determine whether enhanced personal contact with human immunodeficiency virus (HIV)-infected patients across time improves retention in care compared with existing standard of care (SOC) practices, and whether brief skills training improves retention beyond enhanced contact. Methods. The study, conducted at 6 HIV clinics in the United States, included 1838 patients with a recent history of inconsistent clinic attendance, and new patients. Each clinic randomized participants to 1 of 3 arms and continued to provide SOC practices to all enrollees: enhanced contact with interventionist (EC) (brief face-to-face meeting upon returning for care visit, interim visit call, appointment reminder calls, missed visit call); EC + skills (organization, problem solving, and communication skills); or SOC only. The intervention was delivered by project staff for 12 months following randomization. The outcomes during that 12-month period were (1) percentage of participants attending at least 1 primary care visit in 3 consecutive 4-month intervals (visit constancy), and (2) proportion of kept/scheduled primary care visits (visit adherence). Results. Log-binomial risk ratios comparing intervention arms against the SOC arm demonstrated better outcomes in both the EC and EC + skills arms (visit constancy: risk ratio [RR], 1.22 [95% confidence interval {CI}, 1.09-1.36] and 1.22 [95% CI, 1.09-1.36], respectively; visit adherence: RR, 1.08 [95% CI, 1.05-1.11] and 1.06 [95% CI, 1.02-1.09], respectively; all Ps < .01). Intervention effects were observed in numerous patient subgroups, although they were lower in patients reporting unmet needs or illicit drug use. Conclusions. Enhanced contact with patients improved retention in HIV primary care compared with existing SOC practices. A brief patient skill-building component did not improve retention further. Additional intervention elements may be needed for patients reporting illicit drug use or who have unmet needs.
    Clinical Infectious Diseases 09/2014; 59(5):725-734. DOI:10.1093/cid/ciu357 · 9.42 Impact Factor
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    ABSTRACT: Background. The continuum of care is at the forefront of the domestic human immunodeficiency virus (HIV) agenda, with the Institute of Medicine (IOM) and Department of Health and Human Services (DHHS) recently releasing clinical core indicators. Core indicators for retention in care are calculated based on attended HIV care clinic visits. Beyond these retention core indicators, we evaluated the additional prognostic value of missed clinic visits for all-cause mortality. Methods. We conducted a multisite cohort study of 3672 antiretroviral-naive patients initiating antiretroviral therapy (ART) during 2000-2010. Retention in care was measured by the IOM and DHHS core indicators (2 attended visits at defined intervals per 12-month period), and also as a count of missed primary HIV care visits (no show) during a 24-month measurement period following ART initiation. All-cause mortality was ascertained by query of the Social Security Death Index and/or National Death Index, with adjusted survival analyses starting at 24 months after ART initiation. Results. Among participants, 64% and 59% met the IOM and DHHS retention core indicators, respectively, at 24 months. Subsequently, 332 patients died during 16 102 person-years of follow-up. Failure to achieve the IOM and DHHS indicators through 24 months following ART initiation increased mortality (hazard ratio [HR] = 2.23; 95% confidence interval [CI], 1.79-2.80 and HR = 2.36; 95% CI, 1.89-2.96, respectively). Among patients classified as retained by the IOM or DHHS clinical core indicators, >2 missed visits further increased mortality risk (HR = 3.61; 95% CI, 2.35-5.55 and HR = 3.62; 95% CI, 2.30-5.68, respectively). Conclusions. Beyond HIV retention core indicators, missed clinic visits were independently associated with all-cause mortality. Caution is warranted in relying solely upon retention in care core indicators for policy, clinical, and programmatic purposes.
    Clinical Infectious Diseases 08/2014; 59(10). DOI:10.1093/cid/ciu603 · 9.42 Impact Factor
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    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. DOI:10.1097/JTO.0000000000000161 · 5.80 Impact Factor
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    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 11/2013; 9:729-737. DOI:10.2147/VHRM.S50537
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    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; DOI:10.1089/apc.2013.0105 · 3.58 Impact Factor
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    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 02/2013; 8(2):e55525. DOI:10.1371/journal.pone.0055525 · 3.53 Impact Factor
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    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
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    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. DOI:10.1093/cid/cis654 · 9.42 Impact Factor
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    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; 61(5). DOI:10.1097/QAI.0b013e318273762f · 4.39 Impact Factor
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    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; DOI:10.1097/QAI.0b013e3182712d39 · 4.39 Impact Factor
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    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. DOI:10.1093/cid/cis623 · 9.42 Impact Factor
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    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. DOI:10.1016/j.athoracsur.2011.11.012 · 3.65 Impact Factor
  • Clinical Infectious Diseases 12/2011; 53(11):1168-9; author's reply 1169-70. DOI:10.1093/cid/cir678 · 9.42 Impact Factor
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    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. DOI:10.1097/QAI.0b013e31821e9d59 · 4.39 Impact Factor
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    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. DOI:10.1089/aid.2009.0274 · 2.46 Impact Factor
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    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. DOI:10.1059/0003-4819-152-11-201006010-00003 · 16.10 Impact Factor
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    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 03/2010; 354(1):40-44. DOI:10.1016/j.jim.2010.01.008 · 2.01 Impact Factor

Publication Stats

3k Citations
638.39 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
      • Department of Medicine
      Houston, Texas, United States
  • 2000–2013
    • Johns Hopkins Medicine
      • • Department of Medicine
      • • Division of Infectious Diseases
      Baltimore, Maryland, United States
  • 2010
    • National Institute of Allergy and Infectious Diseases
      • Laboratory of Immunoregulation
      Maryland, United States