Jeanne C Keruly

Johns Hopkins University, Baltimore, Maryland, United States

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Publications (79)679.05 Total impact

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    ABSTRACT: Objective: We evaluated whether heavy alcohol use, illicit drug use or high levels of anxiety and depression symptoms were modifiers of the Retention through Enhanced Personal Contact ('REPC') intervention. The intervention had previously demonstrated overall efficacy in the parent study. Design: Randomized trial. Methods: A total of 1,838 patients from 6 U.S. HIV clinics were enrolled into a randomized trial in which intervention patients received an "enhanced contact" protocol for 12 months. All participants completed an ACASI interview that measured depression and anxiety symptoms from the Brief Symptom Inventory, alcohol use from the AUDIT-C instrument, and drug use from the WHO (ASSIST) questions. The 12-month binary outcome was completing an HIV primary care visit in three consecutive 4-month intervals. The outcome was compared between intervention and standard of care patients within subgroups on the effect modifier variables using log-binomial regression models. Results: Persons with high levels of anxiety or depression symptoms and those reporting illicit drug use, or heavy alcohol consumption had no response to the intervention. Patients without these "higher-risk" characteristics responded significantly to the intervention. Further analysis revealed higher-risk patients were less likely to have successfully received the telephone contact component of the intervention. Among higher-risk patients who did successfully receive this component, the intervention effect was significant. Conclusions: Our findings suggest that clinic-based retention in care interventions are able to have significant effects on HIV patients with common behavioral health issues, but the design of those interventions should assure successful delivery of intervention components to increase effectiveness.
    No preview · Article · Jan 2016 · AIDS (London, England)
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    Full-text · Dataset · Aug 2015
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    ABSTRACT: We explored the contribution of missed primary HIV care visits ("no-show") to observed disparities in virological failure (VF) among Black persons and persons with injection drug use (IDU) history. We used patient-level data from 6 academic clinics, before the Centers for Disease Control and Prevention and Health Resources and Services Administration Retention in Care intervention. We employed staged multivariable logistic regression and multivariable models stratified by no-show visit frequency to evaluate the association of sociodemographic factors with VF. We used multiple imputations to assign missing viral load values. Among 10 053 patients (mean age = 46 years; 35% female; 64% Black; 15% with IDU history), 31% experienced VF. Although Black patients and patients with IDU history were significantly more likely to experience VF in initial analyses, race and IDU parameter estimates were attenuated after sequential addition of no-show frequency. In stratified models, race and IDU were not statistically significantly associated with VF at any no-show level. Because missed clinic visits contributed to observed differences in viral load outcomes among Black and IDU patients, achieving an improved understanding of differential visit attendance is imperative to reducing disparities in HIV. (Am J Public Health. Published online ahead of print August 13, 2015: e1-e8. doi:10.2105/AJPH.2015.302695).
    No preview · Article · Aug 2015 · American Journal of Public Health
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    ABSTRACT: HIV RNA viral load (VL) is a pivotal outcome variable in studies of HIV infected persons. We propose and investigate two frameworks for analyzing VL: (1) a single-measure VL (SMVL) per participant and (2) repeated measures of VL (RMVL) per participant. We compared these frameworks using a cohort of 720 HIV patients in care (4,679 post-enrollment VL measurements). The SMVL framework analyzes a single VL per participant, generally captured within a "window" of time. We analyzed three SMVL methods where the VL binary outcome is defined as suppressed or not suppressed. The omit-participant method uses a 8-month "window" (-6/+2 months) around month 24 to select the participant's VL closest to month 24 and removes participants from the analysis without a VL in the "window". The set-to-failure method expands on the omit-participant method by including participants without a VL within the "window" and analyzes them as not suppressed. The closest-VL method analyzes each participant's VL measurement closest to month 24. We investigated two RMVL methods: (1) repeat-binary classifies each VL measurement as suppressed or not suppressed and estimates the proportion of participants suppressed at month 24, and (2) repeat-continuous analyzes VL as a continuous variable to estimate the change in VL across time, and geometric mean (GM) VL and proportion of participants virally suppressed at month 24. Results indicated the RMVL methods have more precision than the SMVL methods, as evidenced by narrower confidence intervals for estimates of proportion suppressed and risk ratios (RR) comparing demographic strata. The repeat-continuous method had the most precision and provides more information than other considered methods. We generally recommend using the RMVL framework when there are repeated VL measurements per participant because it utilizes all available VL data, provides additional information, has more statistical power, and avoids the subjectivity of defining a "window."
    Full-text · Article · Jun 2015 · PLoS ONE
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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.
    No preview · Article · Apr 2015 · AIDS and Behavior
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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.
    No preview · Article · Dec 2014 · JAIDS Journal of Acquired Immune Deficiency Syndromes
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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.
    No preview · Article · Dec 2014 · JAIDS Journal of Acquired Immune Deficiency Syndromes
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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.
    Full-text · Article · Sep 2014 · Clinical Infectious Diseases
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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.
    No preview · Article · Aug 2014 · Clinical Infectious Diseases
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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.
    Full-text · Article · Jun 2014 · Journal of thoracic oncology: official publication of the International Association for the Study of Lung Cancer
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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.
    Full-text · Article · Nov 2013 · Vascular Health and Risk Management
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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.
    No preview · Article · Jul 2013 · AIDS patient care and STDs
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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.
    Preview · Article · Feb 2013 · PLoS ONE
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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.
    No preview · Conference Paper · Oct 2012
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    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.
    Preview · Article · Sep 2012 · Clinical Infectious Diseases
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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 6 commonly used retention measures in predicting viral load (VL) suppression and the correlation among measures. Methods: Clinic-wide patient-level data from 6 academic HIV clinics were used for 12 months preceding implementation of the Centers for Disease Control and Prevention/Health Resources and Services Administration (CDC/HRSA) retention in care intervention. Six retention measures were calculated for each patient based on scheduled primary HIV provider visits: count and dichotomous missed visits, visit adherence, 6-month gap, 4-month visit constancy, and the HRSA HIV/AIDS Bureau (HRSA HAB) retention measure. Spearman correlation coefficients and separate unadjusted logistic regression models compared retention measures with 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, 8235 (82%) had 12-month VL measures, with 6304 (77%) achieving suppression (VL <400 copies/mL). All 6 retention measures were significantly associated (P < 0.0001) with VL suppression (odds ratio; 95% CI, c-statistic): missed visit count (0.73; 0.71 to 0.75, 0.67), missed visit dichotomous (3.2; 2.8 to 3.6, 0.62), visit adherence (3.9; 3.5 to 4.3,0.69), gap (3.0; 2.6 to 3.3, 0.61), visit constancy (2.8; 2.5 to 3.0, 0.63), and HRSA HAB (3.8; 3.3 to 4.4, 0.59). Measures incorporating "no-show" visits were highly correlated (Spearman coefficient = 0.83-0.85), as were measures based solely on kept visits (Spearman coefficient = 0.72-0.77). Correlation coefficients were lower across these 2 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.
    No preview · Article · Sep 2012 · JAIDS Journal of Acquired Immune Deficiency Syndromes
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    ABSTRACT: Background: We evaluated the longitudinal association of alcohol use with immunologic 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. Immunologic 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 in 100, 150, and 200 CD4 cells per cubic millimeter per additional drink per drinking day. Analyses were stratified by sex. Viral suppression was examined as a time-varying covariate. Results: Between 2000 and 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 sex 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 per cubic millimeter, respectively. Conclusions: Among individuals initiating 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.
    No preview · Article · Sep 2012 · JAIDS Journal of Acquired Immune Deficiency Syndromes
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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.
    Full-text · Article · Jul 2012 · Clinical Infectious Diseases
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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.
    Full-text · Article · Feb 2012 · The Annals of thoracic surgery
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    Full-text · Article · Dec 2011 · Clinical Infectious Diseases

Publication Stats

4k Citations
679.05 Total Impact Points

Institutions

  • 1991-2015
    • Johns Hopkins University
      • • Division of Infectious Diseases
      • • Department of Medicine
      Baltimore, Maryland, United States
  • 2000-2013
    • Johns Hopkins Medicine
      • Department of Medicine
      Baltimore, Maryland, United States