ABSTRACT: HIV/AIDS-associated and non-HIV/AIDS-associated death rates and causes of death between 1993 and 1999 were examined in 885
HIV-infected women and 425 uninfected women of the HIV Epidemiology Research Study cohort. Causes of death were determined
by review of death certificates and the National Death Index. Adjusted bazard ratios were calculated for mortality risk factors.
In the 885 HIV-infected women and 425 uninfected women, 234 deaths and 8 deaths, respectively, occurred by December 31, 1999.
All-cause death rates in the HIV-infected women were unchanged between the pre-HAART (1993–1996) and HAART eras (1997–1999)
—5.1 versus 5.4 deaths per 100 person-years (py). AIDS as a cause of death decreased from 58% of all deaths in 1996 to 19%
in 1999, while HAART use increased to 42% by the end of 1999. In spite of the modest proportion ever using HAART, HIV-related
mortality rates did decline, particularly in women with CD4+cell counts less than 200/mm3. Drug-related factors were prominent: for the 129 non-AIDS-defining deaths, hepatitis C positivity (relative bazard [RH]
2.6, P<0.001) and injection drug use (RH 1.7, P=0.02) were strong predictors of mortality, but were not significant in the Cox model for 105 AIDS-defining deaths (RH 0.9,
P>30 and RH 0.7, P>.30, respectively. The regression analysis findings, along with the high percentage of non-AIDS deaths attributable to illicit
drug use, suggest that high levels of drug use in this population offset improvements in mortality from declining numbers
of deaths due to AIDS.
Journal of Urban Health 04/2012; 80(4):676-688. · 2.13 Impact Factor
ABSTRACT: To implement biomedical and other intensive HIV prevention interventions cost-effectively, busy care providers need validated, rapid, risk screening tools for identifying persons at highest risk of incident infection.
To develop and validate an index, we included behavioral and HIV test data from initially HIV-uninfected men who have sex with men who reported no injection drug use during semiannual interviews in the VaxGen VAX004 study and Project Explore HIV prevention trials. Using generalized estimating equations and logistic regression analyses, we identified significant predictors of incident HIV infection, then weighted and summed their regression coefficients to create a risk index score.
The final logistic regression model included age, and the following behaviors reported during the past 6 months: total number of male sex partners, total number of HIV-positive male sex partners, number of times the participant had unprotected receptive anal sex with a male partner of any HIV status, number of times the participant had insertive anal sex with an HIV-positive male partner, whether the participant reported using poppers, and whether they reported using amphetamines. The area under the receiver operating characteristic curve was 0.74, possible scores on index range from 0 to 47 and a score ≥10 had as sensitivity of 84% and a specificity of 45%, levels appropriate for a screening tool.
We developed an easily administered and scored 7-item screening index with a cutoff that is predictive of HIV seroconversion in 2 large prospective cohorts of US men who have sex with men. The index can be used to prioritize patients for intensive HIV prevention efforts (eg, preexposure prophylaxis).
JAIDS Journal of Acquired Immune Deficiency Syndromes 04/2012; 60(4):421-7. · 4.43 Impact Factor
American journal of obstetrics and gynecology 08/2011; · 3.28 Impact Factor
ABSTRACT: Approximately half of HIV-discordant heterosexual couples in the United States want children. Oral antiretroviral preexposure prophylaxis, if effective in reducing heterosexual HIV transmission, might be an option for discordant couples wanting to conceive. Couples should receive services to ensure they enter pregnancy in optimal health and receive education about all conception methods that reduce the risk of HIV transmission. In considering whether preexposure prophylaxis is indicated, the question is whether it contributes to lowering risk in couples who have decided to conceive despite known risks. If preexposure prophylaxis is used, precautions similar to those in the current heterosexual preexposure prophylaxis trials would be recommended, and the unknown risks of preexposure prophylaxis used during conception and early fetal development should be considered. Anecdotal reports suggest that oral preexposure prophylaxis use is already occurring. It is time to have open discussions of when and how preexposure prophylaxis might be indicated for HIV-discordant couples attempting conception.
American journal of obstetrics and gynecology 03/2011; 204(6):488.e1-8. · 3.28 Impact Factor
ABSTRACT: The most effective means of preventing human immunodeficiency virus (HIV) infection is preventing exposure. The provision of antiretroviral drugs to prevent HIV infection after unanticipated sexual or injection-drug--use exposure might be beneficial. The U.S. Department of Health and Human Services (DHHS) Working Group on Nonoccupational Postexposure Prophylaxis (nPEP) made the following recommendations for the United States. For persons seeking care < or =72 hours after nonoccupational exposure to blood, genital secretions, or other potentially infectious body fluids of a person known to be HIV infected, when that exposure represents a substantial risk for transmission, a 28-day course of highly active antiretroviral therapy (HAART) is recommended. Antiretroviral medications should be initiated as soon as possible after exposure. For persons seeking care < or =72 hours after nonoccupational exposure to blood, genital secretions, or other potentially infectious body fluids of a person of unknown HIV status, when such exposure would represent a substantial risk for transmission if the source were HIV infected, no recommendations are made for the use of nPEP. Clinicians should evaluate risks and benefits of nPEP on a case-by-case basis. For persons with exposure histories that represent no substantial risk for HIV transmission or who seek care >72 hours after exposure, DHHS does not recommend the use of nPEP. Clinicians might consider prescribing nPEP for exposures conferring a serious risk for transmission, even if the person seeks care >72 hours after exposure if, in their judgment, the diminished potential benefit of nPEP outweighs the risks for transmission and adverse events. For all exposures, other health risks resulting from the exposure should be considered and prophylaxis administered when indicated. Risk-reduction counseling and indicated intervention services should be provided to reduce the risk for recurrent exposures.
MMWR. Recommendations and reports: Morbidity and mortality weekly report. Recommendations and reports / Centers for Disease Control 02/2005; 54(RR-2):1-20.
ABSTRACT: Data from a prospective, multi-centred study of HIV infection in women (HIV Epidemiology Research Study [HERS]) was analysed to investigate the effect of continued injection drug use behaviours on progression to AIDS. All women enrolled in the HERS had at enrollment and at six-month intervals, a face-to-face interview which included specific injection drug use, a physical exam, and specimen collection that included T-cell subset analysis and HIV plasma RNA detection. Six hundred and thirty-nine HIV-infected women contributed 3021 person years of observation during 7.25 years of follow-up, and 299 of these women progressed to AIDS (46.8%). In multivariable analysis, there was no significantly increased risk of progression to AIDS for women reporting pre-baseline injection drug use [hazard ratio (HR)=1.07 (0.78, 1.47)] or reported injection drug use during follow-up [HR=0.89 (0.66, 1.21)] compared with never injecting. In a separate multivariable-model, comparing women who reported no injection in past six months to active injection drug users, the frequency of injection during the previous six months measured by daily injection [HR=0.97 (0.61, 1.55)] or less than daily injection [HR=0.84 (0.54, 1.33)] was not associated with progression to AIDS. Being in drug treatment was independently associated with a slower progression to AIDS [HR=0.41 (0.28, 0.59)]. Neither injection drug use, nor frequency of injection drug use was associated with progression to AIDS among HIV infected women. Initiation of antiretroviral therapy among drug users should be based on readiness for treatment rather than concern about faster progression.
International Journal of STD & AIDS 06/2004; 15(5):322-7. · 1.09 Impact Factor
ABSTRACT: HIV/AIDS-associated and non-HIV/AIDS-associated death rates and causes of death between 1993 and 1999 were examined in 885 HIV-infected women and 425 uninfected women of the HIV Epidemiology Research Study cohort. Causes of death were determined by review of death certificates and the National Death Index. Adjusted hazard ratios were calculated for mortality risk factors. In the 885 HIV-infected women and 425 uninfected women, 234 deaths and 8 deaths, respectively, occurred by December 31, 1999. All-cause death rates in the HIV-infected women were unchanged between the pre-HAART (1993-1996) and HAART eras (1997-1999)-5.1 versus 5.4 deaths per 100 person-years (py). AIDS as a cause of death decreased from 58% of all deaths in 1996 to 19% in 1999, while HAART use increased to 42% by the end of 1999. In spite of the modest proportion ever using HAART, HIV-related mortality rates did decline, particularly in women with CD4+ cell counts less than 200/mm(3). Drug-related factors were prominent: for the 129 non-AIDS-defining deaths, hepatitis C positivity (relative hazard [RH] 2.6, P <.001) and injection drug use (RH 1.7, P = 0.02) were strong predictors of mortality, but were not significant in the Cox model for 105 AIDS-defining deaths (RH 0.9, P >.30 and RH 0.7, P >.30, respectively. The regression analysis findings, along with the high percentage of non-AIDS deaths attributable to illicit drug use, suggest that high levels of drug use in this population offset improvements in mortality from declining numbers of deaths due to AIDS.
Journal of Urban Health 12/2003; 80(4):676-88. · 2.13 Impact Factor
ABSTRACT: Viruses that can persist in the host are of special concern in immunocompromised populations. Among 871 human immunodeficiency virus (HIV)-infected and 439 high-risk HIV-uninfected women, seroprevalences of cytomegalovirus, hepatitis B virus, hepatitis C virus, and herpes simplex virus types 1 and 2 and prevalence of human papillomavirus DNA in cervicovaginal lavage fluids were all >50% and were 2-30 times higher than prevalences in the general population. Prevalences were highest among HIV-infected women, of whom 44.2% had >or=5 other infections, and were relatively high even among the youngest women (age 16-25 years). In multivariate analyses, viral infections were independently associated not only with behaviors such as injection drug use and commercial sex but also with low income, low levels of education, and black race. Disadvantaged women and women who engage in high-risk behaviors are more likely to be coinfected with HIV and other viruses and, thus, may be at high risk of serious disease sequelae.
The Journal of Infectious Diseases 05/2003; 187(9):1388-96. · 6.41 Impact Factor
ABSTRACT: To examine the relationship between antiretroviral adherence and viral load, and to determine the predictors of adherence over time in HIV-infected women.
Prospective observational study.
One-hundred sixty-one HIV-infected women who were taking antiretroviral therapy for a median of 3.0 years were recruited from the HIV Epidemiology Research Study, a multicenter cohort study of HIV infection in women. Antiretroviral adherence (percent of doses taken as prescribed) was measured over a 6-month period using MEMS caps. At baseline and follow-up, CD4 lymphocyte count and viral load were measured, and a standardized interview was administered to elicit medication history and drug use behaviors. To examine changes in adherence over time, the mean adherence to all antiretroviral agents was calculated for each monitored month.
Adherence varied significantly over time (P < 0.001), ranging from a mean of 64% in month 1 to 45% in month 6. Nearly one-fourth of the participants had a 10% or greater decrease in adherence between consecutive months. Virologic failure occurred in 17% of women with adherence of > or = 88%, 28% of those with 45-87% adherence, 43% of those with 13-44% adherence, and 71% of those with < or = 12% adherence. In multivariate analysis, factors predicting lower adherence included active drug use, alcohol use, more frequent antiretroviral dosing, shorter duration of antiretroviral use, younger age, and lower initial CD4 lymphocyte count.
Antiretroviral adherence is not stable over time. Interventions aimed at monitoring and improving long-term adherence in women are urgently needed.
AIDS 11/2002; 16(16):2175-82. · 6.24 Impact Factor
ABSTRACT: The purpose of this study was to determine the risk for urinary tract infection in women with or at risk for human immunodeficiency virus infection.
A prospective study of 871 women who were human immunodeficiency virus seropositive and 439 women who were human immunodeficiency virus seronegative was conducted, with additional semiannual interviews, human immunodeficiency virus serologic evaluation, human immunodeficiency viral load determination, T-cell subset test, urinalysis, pregnancy test, and selected quantitative urine culture examination.
At baseline, 26 women (3.0%) who were human immunodeficiency virus seropositive and 14 women (3.2%) who were human immunodeficiency virus seronegative women had urinary tract infections(P =.97). During 4280 person-years of follow-up, incident urinary tract infections was associated significantly with <12 years education (adjusted risk ratio, 1.43; 95% CI, 1.01-2.00), public assistance (adjusted risk ratio, 1.70; 95% CI, 1.11-2.60), pregnancy (adjusted risk ratio, 3.04; 95% CI, 2.04-4.53), and recent previous urinary tract infection (adjusted risk ratio, 1.82; 95% CI, 1.16-2.86), but not with human immunodeficiency virus infection. Among women who were human immunodeficiency virus seropositive, risk was associated with viral load (adjusted risk ratio, per log(10) increase 1.30; 95% CI, 1.03-1.63), but not with CD(4+) lymphocyte count.
Risk for urinary tract infection is not associated with human immunodeficiency virus infection but is associated with viral load among women who are infected with human immunodeficiency virus.
American Journal of Obstetrics and Gynecology 10/2002; 187(3):581-8. · 3.47 Impact Factor
ABSTRACT: To evaluate factors associated with use of HIV specialist care by women, and to determine whether medical indications for therapy validate lower rates of antiretroviral use in women not using HIV specialty care.
Cross-sectional analysis of the 1998 interview from the HIV Epidemiology Research Study (HERS) cohort.
Data from 273 HIV-infected women in the HERS were analyzed by multiple logistic regression to calculate predictors of the use of HIV specialist care providers. Variables included study site, age, education, insurance status, income, substance abuse, depression, AIDS diagnosis, CD4 + lymphocyte count, and HIV-1 viral load. In addition, medical indications for therapy and medical advice to begin antiretroviral therapy were assessed.
Of 273 women, 222 (81%) used HIV specialists and 51 (19%) did not. Having health insurance, not being an injection drug user, and being depressed were predictive of using HIV specialist care (all p < or = .05). Although medical indications for therapy in the two groups were comparable, the rate of highly active antiretroviral therapy (HAART) use was significantly higher in women using HIV specialist care (27%) compared with those not using HIV specialists (7.8%). Women using HIV specialists received significantly more advice to begin antiretroviral therapy (ART) in the 6 months prior to the interview compared with those not using specialists (relative risk, 2.4; 95% CI = 1.3-4.6).
Having insurance, not being an injection drug user, and being depressed all increased the likelihood of women receiving HIV specialty care, which, in turn, increased the likelihood of receiving recommended therapies. The level of HAART use (23%) and any ART use (47%) in these HIV-infected women was disturbingly low. Despite comparable medical indications, fewer women obtaining care from other than HIV specialists received HAART. These data indicate substantial gaps in access to HIV specialist care and thereby to currently recommended antiretroviral treatment.
JAIDS Journal of Acquired Immune Deficiency Syndromes 01/2002; 29(1):69-75. · 4.43 Impact Factor
ABSTRACT: Objectives: To compare the prevalence of HIV-related symptoms, physical examination findings, and hematologic variables among women whose risk for HIV is injection drug use since 1985 as opposed to sexual contact and to evaluate the influence of HIV plasma viral load and CD4+ cell count on clinical manifestations according to risk.
Methods: Participants of the HIV Epidemiology Research Study (HERS; a multicenter, prospective, controlled study of HIV infection in women) were administered a risk behavior and symptom interview, underwent a physical examination, and received hematologic testing, including CD4+ cell counts done on study entry. Plasma HIV-1 viral loads were performed on stored frozen plasma using an ultrasensitive branched-DNA (b-DNA) signal amplification assay. CD4+ counts were categorized as <200 cells/μl, 200 to 499 cells/μl, or ≥500 cells/μl, and HIV viral loads were characterized in tertiles.
Results: Cross-sectional analysis was conducted on data available for 724 HIV-infected women: 387 had a history of intravenous drug use and 337 were infected through heterosexual contact. The median CD4+ count was 376 cells/μl; the median HIV-1 viral load was 1135 copies/ml; and 281 of 724 HIV-infected women (38.8%) had an undetectable HIV-1 viral load. In analyses adjusting for CD4+ cell level alone and for plasma viral load combined with CD4+ cell level, injection drug users (IDUs) were more likely than those infected through heterosexual contact to report a recent episode of memory loss and weight loss, but less likely to have recent episodes of genital herpes; to have enlarged livers and a body mass index (BMI) <24, and to have hematocrit levels <34% and platelet counts <150,000 cells/ml. After adjustment for CD4+ cell level and risk group, high and medium HIV-1 plasma viral load levels were associated with the presence of oral hairy leukoplakia on examination, and only the highest level of plasma viral load was associated with recent histories of fever and thrush, oral hairy leukoplakia, pseudomembranous candidiasis, and BMI <24 on examination, and hematocrit <34%.
Conclusions: In this cohort of women, the distribution of HIV-1 plasma viral load was lower than that previously reported in populations of HIV-infected men. This study also shows some differences in frequency of signs, symptoms, and laboratory values between risk groups of HIV-infected women, but these results may be due to effects of injection drug use rather than HIV infection. Signs and symptoms identified as associated with increasing levels of viral load that were not different across risk groups suggest more direct association of these findings with HIV infection.
JAIDS Journal of Acquired Immune Deficiency Syndromes 04/1999; 20(5):448-454. · 4.43 Impact Factor
ABSTRACT: In April 2007, the Centers for Disease Control and Prevention (CDC) held a two-day consultation with a broad spectrum of stakeholders to obtain input on the potential role of male circumcision (MC) in preventing transmission of human immunodeficiency virus (HIV) in the U.S. Working groups summarized data and discussed issues about the use of MC for prevention of HIV and other sexually transmitted infections among men who have sex with women, men who have sex with men (MSM), and newborn males. Consultants suggested that (1) sufficient evidence exists to propose that heterosexually active males be informed about the significant but partial efficacy of MC in reducing risk for HIV acquisition and be provided with affordable access to voluntary, high-quality surgical and risk-reduction counseling services; (2) information about the potential health benefits and risks of MC should be presented to parents considering infant circumcision, and financial barriers to accessing MC should be removed; and (3) insufficient data exist about the impact (if any) of MC on HIV acquisition by MSM, and additional research is warranted. If MC is recommended as a public health method, information will be required on its acceptability and uptake. Especially critical will be efforts to understand how to develop effective, culturally appropriate public health messages to mitigate increases in sexual risk behavior among men, both those already circumcised and those who may elect MC to reduce their risk of acquiring HIV.
Public Health Reports 125 Suppl 1:72-82. · 1.27 Impact Factor
During the past decade, knowledge of human immunodeficiency virus (HIV)
infection in women has expanded considerably but may not be easily accessible
for use in understanding and prioritizing the clinical needs of HIV-infected
To perform a comprehensive review of epidemiologic, clinical, psychosocial,
and behavioral information about HIV in women, and to recommend an agenda
for future activities.Data Sources
A computerized search, using MEDLINE and AIDSline, of published literature
was conducted; journal articles from January 1981 through July 2000 and scientific
conference presentations from January 1999 through July 2000 were retrieved
and reviewed for content; article reference lists were used to identify additional
articles and presentations of interest.Study Selection
Data from surveillance and prospective cohort studies with at least
20 HIV-infected women and appropriate comparison groups were preferentially
Included studies of historical importance and subsequent refined analyses
of topics covered therein; these and studies with more current data were given
preference. Four studies involving fewer than 20 women were included; 2 studies
were of men only.Data Synthesis
Women account for an increasing percentage of all acquired immunodeficiency
syndrome (AIDS) cases, from 6.7% (1819/27 140 cases) in 1986 to 18% (119 810/724 656
cases) in 1999. By the end of 1998, of all newly reported AIDS cases among
women, proportionally more were in the South (41%), among black women (61%),
and from heterosexual transmission (38%). Of note, increasingly more women
have no identified or reported risk, about half or more of whom are estimated
to be infected heterosexually. It is estimated that a total of at least 54%
of women newly reported with AIDS in 1998 acquired HIV through heterosexual
sex, including women in the no identified or reported risk category estimated
to have been infected heterosexually, meeting the surveillance heterosexual
risk definition. Natural history, progression, survival, and HIV-associated
illnesses—except for those of the reproductive tract—thus far
appear to be similar in HIV-infected women and men. Although antiretroviral
therapy has proven to be highly effective in improving HIV-related morbidity
and mortality rates, women may be less likely than men to use these therapies.
Drug use, high-risk sex behaviors, depression, and unmet social needs interfere
with women's use of available HIV prevention and treatment resources.Conclusions
Continued research on HIV pathogenesis and treatment is needed; however,
emphasis should also be placed on using existing knowledge to improve the
clinical care of women by enhancing use of available services and including
greater use of antiretroviral therapy options, treating depression and drug
use, facilitating educational efforts, and providing social support for HIV-infected
Figures in this Article
Acquired immunodeficiency syndrome (AIDS), first reported in women in
1981,1 had become the sixth leading cause of
death in 25- to 44-year-old women in the United States by 1990.2
Many unanswered questions arose about the natural history and progression
of human immunodeficiency virus (HIV) disease in women,2- 3
the survival of HIV-infected women,3 the appropriateness
of AIDS case definitions for them,4 and the
burden and manifestations of HIV-associated illnesses,4
particularly for sex-specific diseases.
To help answer these questions, epidemiologic studies were stratified
by sex more frequently, clinical trials enrolled more women, and prospective
studies were developed to focus on specific diseases in HIV-infected women.
Also, 2 large prospective cohort studies of HIV-infected women and women at
risk for HIV in the United States were created to examine a comprehensive
set of questions: the Human Immunodeficiency Virus Research Study (HERS),
started in 1991,5 and the Women's Interagency
HIV Study (WIHS), started in 1994.6
In the United States, HIV infection remains a substantial problem for
women. In 1998, AIDS was the fifth leading cause of death for women aged 25
to 44 years, and the third leading cause of death for black women in this
age group.7 However, the past decade of research
has led to a considerable expansion of knowledge regarding HIV infection in
women. Because the results of research have been presented in a variety of
settings, such as at conferences, in specialty journals, and within articles
addressing issues not specific to HIV-infected women, this body of knowledge
is not always easily accessible to clinicians or persons living with HIV/AIDS.
Thus, we performed a comprehensive review of clinical literature relevant
to HIV infection in women in the United States to enhance accessibility of
this information so that it could be more readily used to improve the care
of HIV-infected women. Literature on maternal-child HIV transmission has been
recently reviewed in detail elsewhere8- 9
and will not be extensively addressed herein.
JAMA The Journal of the American Medical Association 285(9):1186-1192. · 30.03 Impact Factor