Human Immunodeficiency Virus Risk Factors Research Articles

Practice Parameter for the Assessment and Treatment of Children and Adolescents With Substance Use Disorders

Practice Parameter for the Assessment and Treatment of Children and Adolescents With Substance Use Disorders

Diagnosis of Colitis: Making the Initial Diagnosis

The evaluation of patients with colitis of recent onset is a relatively common clinical challenge. The main considerations are infectious colitides, idiopathic IBD, ie, ulcerative and Crohn's colitis, and colonic ischemia. An initial risk assessment on the basis of such factors as concurrent symptoms in contacts, travel history, medications, and human immunodeficiency virus risk factors should be followed by a thorough clinical history, physical examination, stool studies, blood tests, and, in selected cases, endoscopic examination and serologic tests. Biopsies can be decisive in distinguishing among the different types of acute colitis and might help identify specific etiologies. The diagnostic yield of biopsies is maximized by appropriate sampling of the colonic mucosa and by sharing the clinical and endoscopic findings with the pathologist, eg, via a copy of the endoscopy report.

Estimation of HIV Prevalence, Risk Factors, and Testing Frequency among Sexually Active Men Who Have Sex with Men, Aged 18–64 Years—New York City, 2002

Population-based estimates of human immunodeficiency virus (HIV) prevalence and risk behaviors among men who have sex with men (MSM) are valuable for HIV prevention planning but not widely available, especially at the local level. We combined two population-based data sources to estimate prevalence of diagnosed HIV infection, HIV-associated risk-behaviors, and HIV testing patterns among sexually active MSM in New York City (NYC). HIV/AIDS surveillance data were used to determine the number of living males reporting a history of sex with men who had been diagnosed in NYC with HIV infection through 2002 (23% of HIV-infected males did not have HIV transmission risk information available). Sexual behavior data from a cross-sectional telephone survey were used to estimate the number of sexually active MSM in NYC in 2002. Prevalence of diagnosed HIV infection was estimated using the ratio of HIV-infected MSM to sexually active MSM. The estimated base prevalence of diagnosed HIV infection was 8.4% overall (95% confidence interval [CI] = 7.5-9.6). Diagnosed HIV prevalence was highest among MSM who were non-Hispanic black (12.6%, 95% CI = 9.8-17.6), aged 35-44 (12.6%, 95% CI = 10.4-15.9), or 45-54 years (13.1%, 95% CI = 10.2-18.3), and residents of Manhattan (17.7%, 95% CI = 14.5-22.8). Overall, 37% (95% CI = 32-43%) of MSM reported using a condom at last sex, and 34% (95% CI = 28-39%) reported being tested for HIV in the past year. Estimates derived through sensitivity analyses (assigning a range of HIV-infected males with no reported risk information as MSM) yielded higher diagnosed HIV prevalence estimates (11.0-13.2%). Accounting for additional undiagnosed HIV-infected MSM yielded even higher prevalence estimates. The high prevalence of diagnosed HIV among sexually active MSM in NYC is likely due to a combination of high incidence over the course of the epidemic and prolonged survival in the era of highly active antiretroviral therapy. Despite high HIV prevalence in this population, condom use and HIV testing are low. Combining complementary population-based data sources can provide critical HIV-related information to guide prevention efforts. Individual counseling and education interventions should focus on increasing condom use and encouraging safer sex practices among all sexually active MSM, particularly those groups with low levels of condom use and multiple sex partners.

Gender Difference in the Clinical and Behavioral Characteristics of Human Immunodeficiency Virus-infected Injection Drug Users in Taiwan

Injection drug users (IDUs) have become the major contributors to the human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome epidemic in Taiwan, accounting for more than 60% of new cases in 2005. In Taiwan, gender difference in risk factors for HIV among IDUs has not been reported before. We studied the clinical and sociodemographic characteristics, sexual behaviors, drug use histories and criminal records of male and female HIV-infected IDUs. A total of 100 male and 25 female HIV-infected inmates from two prisons were included. An individually structured interview was conducted with each inmate. Serostatus of hepatitis B virus (HBV) and hepatitis C virus (HCV) were tested. CD4+ T cell count and HIV viral load were also evaluated. The mean age of the HIV-infected inmates was 31.7 +/- 6.4 years. All inmates were co-infected with HCV and 20% were HBV carriers. The mean CD4+ T cell count was 498 cells/microL, and the mean viral load was 20,119 copies/mL. Heroin use history averaged 6.3 +/- 5.1 years, and 84.8% of patients had a previous criminal offense prior to current conviction. Female inmates were significantly younger, had more sexual partners, had more drug-using family members or sexual partners, shared injection paraphernalia more frequently, and started using methamphetamine and heroin at younger ages (p < 0.05). Male inmates tended to be single, had less parental support, had been more frequently convicted of non drug-related crimes, started using non-illicit substances more frequently at younger ages and had sex with prostitutes more frequently (p < 0.05). The results of this study suggest that drug injection risks and sexual behavior related risks are equally important in determining the risk of HIV infection among IDUs. Gender-specific approaches to prevention which reflect differences in gender-related patterns of risk are also needed.

HIV/AIDS: Testing and risk behaviors among Britsh Columbia’s rural Aboriginal population

Objectives. Over the last decade, there has been growing concern in the public health sector over the spread of Human Immunodeficiency Virus (HIV) in Canada’s Aboriginal population. However, there continues to be a general lack of HIV awareness and its risk factors in Aboriginal communities.Study design and methods. This study investigated HIV testing patterns, perceptions and risk factors within 7 community organizations through the use of face-to-face interviews. The objectives of this research project were to 1) describe the prevalence of HIV testing; 2) describe issues concerning confidentiality related to the HIV testing; 3) identify the prevalence of risk factors for HIV transmission; and, 4) build research capacity in the Aboriginal community.Results. Two hundred and nineteen Aboriginal persons participated in interviews. Off-reserve residents (pOR: 0.48, 95% CI: 0.29 – 0.80) were significantly more likely to use illicit drugs than reserve residents. Sixty percent of participants had reported undergoing HIV testing at some point. Two-spirited participants (pOR: 16.1, 95% CI: 2.13–121.06), those who previously tested for a Sexually Transmitted Disease (pOR: 2.94, 95% CI: 1.73-4.98), those currently using cocaine (pOR: 3.88, 95% CI: 1.25 – 12.0), and those who reported to “never”, or “some of the time” use clean needles (pOR: 11.0, 95% CI: 1.36-88.66) were significantly more likely to undergoing HIV testing. On-reserve residents (pOR: 0.55, 95% CI: 0.35-0.87) and respondents older than 40 years of age (pOR: 0.40, 95% CI: 0.19 – 0.86) were less likely to undergo HIV testing.Conclusions. Participants with HIV risk factors are more likely to be tested for HIV in rural areas and confidentiality issues were not a barrier to testing for most participants. Off-reserve residents were more likely to undergo HIV testing, the reasons for which require additional research. Finally, public health units are often under-utilized as locations to seek testing.

Face‐to‐face interviewing in predonation screening: lack of effect on detected human immunodeficiency virus and hepatitis C virus infections

Predonation screening has become more elaborate over the years, while human immunodeficiency virus (HIV)- and hepatitis C virus (HCV)-positive donations have declined. The impact of face-to-face interviewing and of the format of the Donor Health Assessment Questionnaire (DHAQ) have not been evaluated. Canadian Blood Services DHAQ records between 1990 and 2004 were examined, and changes in them were tracked. The proportion of first-time donors permanently deferred for HIV or HCV risk, and the HIV and HCV rates per 100,000 donations, were calculated annually. Time-series analysis was used to determine whether major predonation screening changes had any effect on the HIV or HCV rates or permanent deferrals. In 1992, receiving money or drugs for sex was added to the DHAQ; otherwise, the content of high-risk questions changed little between 1990 and 2004. In 1997, the method of administration of the DHAQ changed from donor-completed to face-to-face interviewing for high-risk questions. Permanent deferrals for HIV or HCV risk factors and HIV and HCV rates in first-time donors decreased over this period. The HIV rates were close to 0 before 1997, whereas HCV rates decreased steadily through 2004. There was no interruption in rates in 1997 when the method of administration changed. Face-to-face interviewing for high-risk questions had no effect on HIV or HCV rates in first-time donations over 15 years of observation (during the latter 8 of which face-to-face interviewing was in place), and it did not increase permanent deferrals for HIV or HCV risk factors.

Use of Efavirenz Is Not Associated with a Higher Risk of Depressive Disorders: A Substudy of the Randomized Clinical Trial ALIZE-ANRS 099

Efavirenz (EFV) is a highly active antiretroviral drug, use of which is associated with frequent (although transient) neurosensorial adverse reactions. Whether the use of EFV is associated with the risk of depression or suicide remains controversial. ALIZE-ANRS (Agence Nationale de Recherches sur le SIDA et les Hepatites Virales) 099 was a 48-week randomized trial involving virologically suppressed, human immunodeficiency virus (HIV)-infected patients that compared the maintenance of a treatment regimen that contained protease inhibitors (177 subjects) with a switch to a once-daily combination of EFV, didanosine, and emtricitabine (178 subjects). We used the trial's adverse events reporting system and a self-administered Center for Epidemiologic Studies-Depression Scale questionnaire to assess depressive disorders. Determinants were studied using a multivariate proportional hazards model adjusted for antiretroviral treatment, sex, age, HIV risk factor, history of depression, hepatic disorder, alcohol abuse, and HIV-related or non-HIV-related events. Thirty cases of depressive disorder (26 cases of depression and 4 suicide attempts) occurred during treatment in 27 patients (12 patients [7%] and 15 patients [8%] in the protease inhibitor-based and EFV-based treatment arms, respectively; P = .56). In the proportional hazards model, only age (hazard ratio, 1.6 per 10 years younger; 95% confidence interval, 1.0-2.6) and a history of depressive disorder (hazard ratio, 5.0; 95% confidence interval, 2.1-12.0) were associated with a risk of depressive disorders. The proportion of depressive patients (24%), as determined on the basis of the Center for Epidemiologic Studies-Depression Scale data, was stable during the follow-up period, without difference between treatment groups. Patients with a history of depressive disorder were more frequently depressed (53%) than were those without such history (22%; P = .03). The frequency of depressive disorders was high in this population, but the disorders were not related to EFV treatment. Younger age and a history of depression are important determinants for depression and should be considered for early detection and case management.

Evaluation of the Centers for Disease Control and Prevention's Recommendations Regarding Routine Testing for Human Immunodeficiency Virus by an Inpatient Service: Who Are We Missing?

To assess the proportion of hospitalized patients who tested positive for human immunodeficiency virus (HIV) by a routine inpatient testing service, as recommended by the Centers for Disease Control and Prevention, who might not have been identified had routine testing not been offered. In this retrospective cohort study, the medical records of patients who tested HIV positive by the inpatient testing service between 1999 and 2003 were compared with the medical records of inpatients who tested HIV negative by the inpatient testing service and the medical records of patients who tested HIV positive in ambulatory settings. We compared HIV risk factors, discharge diagnoses, CD4 cell counts, and HIV RNA concentrations. A total of 243 patients participated in this study: 81 patients who tested HIV positive and 81 who tested HIV negative by the inpatient testing service, and 81 patients who tested HIV positive in ambulatory settings. Both HIV-positive inpatients and HIV-positive outpatients had similar frequencies of HIV risk factors (46% vs 43%; P=.75). Both groups differed significantly from HIV-negative inpatients (4%; P<.001). Comparing HIV-positive inpatients with HIV-positive outpatients, CD4 cell counts were lower (196 vs 371 cells/mm3; P<.001), and HIV RNA levels were higher (4.61 vs 4.09 Iog, HIV RNA; P=.001). At diagnosis, 64 HIV-positive inpatients (79%) met criteria for acquired immunodeficiency syndrome compared with 21 HIV-positive outpatients (26%) (P<.001). Patients who tested HIV positive through inpatient testing have more advanced disease than those identified as outpatients. Half of these patients would not have been identified had testing not been routinely offered. Routine inpatient HIV testing offers an important opportunity to identify patients with HIV infection.

The Cost-Effectiveness of Expanded Testing for Primary HIV Infection

Primary infection with the human immunodeficiency virus (HIV) is a major factor in the HIV epidemic. Most patients become symptomatic and seek care, but seldom are they tested or is their condition diagnosed. The objectives of this study are to determine whether it is cost-effective to expand testing for primary HIV infection to a larger cohort of patients, and, if so, which diagnostic assay is most cost-effective. We undertook a cost-effectiveness analysis of testing a hypothetical cohort of more than 3 million outpatients with fever and other viral symptoms regardless of HIV risk factors using 3 diagnostic assays: p24 antigen enzyme immunosorbent assay (EIA), HIV-1 RNA assay, and third-generation HIV-1 EIA. Antiretroviral therapy was started when the CD4 cell count decreased to 350/microL. Outcome measures were the incremental cost-effectiveness of the diagnostic assays, number of cases identified, cases avoided in sexual partners, and threshold prevalence. For sensitivity analyses, we used 50,000 dollars as the threshold for cost-effectiveness. At the baseline prevalence of 0.66%, p24 antigen EIA testing was the most cost-effective option at a cost of 30,800 dollars per quality-adjusted life-year gained when compared with no testing. There were 17,054 cases identified, and infection was avoided in 435 partners. Probabilistic sensitivity analysis, in which the estimates for all variables are varied simultaneously, determined that expanded testing with p24 antigen EIA compared with no testing had a 67% probability of being cost-effective at the baseline prevalence and a 71% probability at a prevalence of 1%. Expanded testing for primary HIV infection with p24 antigen EIA may be a sound expenditure of health care resources.

HIV encephalitis simulating Huntington's disease

Complications from human immunodeficiency virus (HIV)/acquired immune deficiency syndrome are notorious for mimicking other neurological diseases. We describe a case of HIV encephalitis presenting with the classic clinical features of Huntington's Disease in a woman without known HIV risk factors or other clinical stigmata suggestive of immunosuppression. This case reminds us that HIV should be part of the differential diagnosis in unexplainable neurological diseases.

Human immunodeficiency virus infection in a rural community in the United States.

In 1986, a population-based survey of human immunodeficiency virus (HIV) infection in a rural Florida community showed that HIV prevalence was 28/877 (3.2%, 95% confidence interval (CI): 2.0, 4.4). In 1998-2000, the authors performed a second population-based survey in this community and a case-control study to determine whether HIV prevalence and risk factors had changed. After 609 addresses had been randomly selected for the survey, 516 (85%) residents were enrolled, and 447 (73%) were tested for HIV. HIV prevalence was 7/447 (1.6%, 95% CI: 0.4, 2.7) in western Palm Beach County and 5/286 (1.7%, 95% CI: 0.2, 3.3) in Belle Glade (p=0.2 in comparison with 1986). Independent predictors of HIV infection in both 1986 and 1998-2000 were having a history of sexually transmitted disease, number of sex partners, and exchanging money or drugs for sex. A history of having sex with men was a risk factor among men in 1986 but not in 1998-2000; residence in specific neighborhoods was a risk factor in 1998-2000 but not in 1986. The authors conclude that heterosexually acquired HIV infection did not spread throughout the community between 1986 and 1998 but persisted at a low level in discrete neighborhoods. Interventions targeting HIV-endemic neighborhoods will be needed to further reduce HIV prevalence in this area.

Prevalence of Human Immunodeficiency Virus Testing in Patients With Hepatitis B and C Infection

To determine the proportion of patients with hepatitis B virus (HBV) and hepatitis C virus (HCV) who are adequately assessed for human immunodeficiency virus (HIV) and to identify variables associated with absence of HIV testing. We retrospectively reviewed the medical records of patients who had positive serologic test results for reactive HBV and/or HCV between January 1999 and December 1999 and were followed up at a general internal medicine clinic in East Harlem, NY. Data were collected on patient demographics, HIV risk factors, and other variables that might influence the physician's decision to test the patient for HIV. Primary outcomes were HIV tests performed and documented discussions of at-risk HIV behavior. The HIV tests were performed in 40% (95% confidence interval [CI], 32%-49%) of the 141 patients with reactive HBV and/or HCV serologic test results. Predictors of HIV testing on multivariate logistic regression were age younger than 50 years (odds ratio [OR], 25; 95% CI, 13-3.8), male sex (OR, 1.6; 95% CI, 1.1-2.2), and having an established primary care provider (OR, 2.3; 95% CI, 1.2-3.9). Injection drug use was not significantly associated with HIV testing. Although HBV and HCV have clear epidemiological links with HIV, this study shows that a high percentage of these patients are not being tested. Although some of the factors associated with lack of testing were identified, further studies on the barriers to HIV testing are needed to reveal potential approaches to increase rates of HIV testing in this high-risk population.

The State of Science: Violence and HIV Infection in Women

Violence and human immunodeficiency virus (HIV) are two critical public health problems affecting the lives of millions of women today. The purpose of this article is to review the state of science that exists in linking the phenomena of violence and HIV infection in women. The history and scope of violence and HIV infection is presented. Theoretical models for the phenomena of violence and abuse against women and HIV risk behavior reduction are explored. The literature review consists of 44 research articles that examine risk factors for violence and HIV, violence associated with HIV/AIDS disclosure, history of violence and HIV/AIDS, forced or coercive sex and HIV/AIDS, and violence associated with HIV self-protection conduct. Implications for nursing practice and nursing research are presented.

HIV risk profile and prostitution among female street youths.

The objective of this study was to compare human immunodeficiency virus (HIV) risk factors among female street youths involved in prostitution and those with no history of prostitution. Youths aged 14 to 25 years were recruited into the Montreal Street Youth Cohort. Semiannually, youths completed an interviewer-administered questionnaire. Statistical analyses comparing characteristics and HIV risk factors for girls involved in prostitution and those never involved were carried out using parametric and nonparametric methods. Of the girls, 88 (27%) reported involvement in prostitution, and 177 girls reported no history of prostitution at the baseline interview. Girls involved in prostitution were two times and five times more likely to have reported bingeing on alcohol and on drugs, respectively. A history of injection drug use was four times more likely to have been reported by girls involved in prostitution. Further, these girls were 2.5 times more likely to have reported injected cocaine as their drug of choice. Girls involved in prostitution were younger the first time they had consensual sex and were twice as likely to have reported anal sex. Consistent condom use for anal, vaginal, and oral sex was low for all girls. Girls involved in prostitution reported more risky sexual partners. In conclusion, girls involved in prostitution may be at increased risk of HIV infection due to their injection drug use and risky sexual behaviors. Unique intervention strategies are necessary for reducing HIV infection among female street youths involved in prostitution.

Human Immunodeficiency Virus: The Initial Physician-Patient Encounter

Human Immunodeficiency Virus: The Initial Physician-Patient Encounter

Altered clinical course of malignant melanoma in HIV-positive patients.

To determine whether the natural history of melanoma is different in patients who test positive for human immunodeficiency virus (HIV) compared with matched control subjects. Retrospective cohort analysis. Ambulatory care at 2 university-affiliated medical centers. Each HIV-positive melanoma patient (n = 17) was randomly matched with 2 HIV-negative patients (HIV status unknown, but without risk factors for HIV) based on the melanoma subtype, tumor thickness, Clark level, tumor location, and sex and age of the patient. Disease-free survival and overall survival of HIV-positive and HIV-negative melanoma patients were compared using a matched-pairs analysis. CD4 cell counts were recorded at the time of melanoma diagnosis and disease recurrence. Melanoma patients who were HIV positive had a significantly shorter disease-free survival (P =.03) and overall survival (P =.045) compared with HIV-negative melanoma patients by matched-pairs analysis. There was an inverse relationship between CD4 cell counts and time to first melanoma recurrence. The natural history of malignant melanoma in HIV-positive patients is more aggressive compared with matched HIV-negative melanoma patients. Altered immune response and comorbid disease may play a role in the poor clinical outcome of HIV-positive patients. These findings have important implications in the management of melanoma in the setting of HIV disease.

Cytomegalovirus glycoprotein B groups in human immunodeficiency virus-infected patients with incident retinitis.

Cytomegalovirus (CMV) strains may be categorized into 4 different groups on the basis of glycoprotein B (gB) genotype. gB genotypes in CMV polymerase chain reaction (PCR)-positive samples from case patients who were diagnosed with retinitis during prospective follow-up were compared with genotypes in CMV PCR-positive samples from an equal number of retinitis-free matched control subjects. All patients were infected with human immunodeficiency virus (HIV) and CMV. Control subjects and their plasma samples were matched with case patients according to baseline CD4(+) T cell count, transfusion history, HIV risk factor, and follow-up time. CMV DNA was genotyped by restriction-enzyme digestion. Eighteen patients met our case definition. Approximately one-third of patients had gB genotype 1, and half had gB genotype 2. These rates were similar among case patients and control subjects and were similar by risk group. The CMV gB2 genotype is not a major determinant of retinitis pathogenicity but appears to be highly prevalent among HIV-infected patients.

Infections of the spine in patients with human immunodeficiency virus

Marc Weinstein, MD, Nathan H. Lebwohl, MD, Mark D. Brown, MD, Frank J. Gismont, Miami, FL, USAIntroduction: Infectious diseases in patients with human immunodeficiency virus (HIV) are common and the management of the various bacterial and fungal infections can be a challenge in the immunocompromised host. Skeletal manifestations of patients with HIV have been described in various case reports. Many authors have suggested that spinal infections will occur with greater frequency in the HIV population. However, the incidence and characteristics of spinal infections in these patients have not been reported. The purpose of this study was to evaluate our experience with spinal infections in the HIV population.Methods: The computerized records of all patients discharged with the diagnosis of HIV from our institution from October 1994 through September 2000 were reviewed. Patients with the diagnosis of spinal osteomyelitis, discitis, epidural abscess and tuberculosis were identified, and the charts were examined in detail. In addition to demographic data, the following parameters were recorded: HIV risk factor, admission white blood cell count (WBC), absolute lymphocyte count, erythrocyte sedimentation rate, CD4 count, imaging studies, blood culture results, biopsy results, surgical procedure, antibiotic treatments and duration, length of stay, hospital charges and outcome.Results: For the 6-year period studied, there were 17,717 patient discharges with the diagnosis of HIV. Of these, 17 patients (0.095%) were also treated for a spinal infection. This included eight patients with discitis/osteomyelitis, six patients with tuberculosis (TB) and three patients with an epidural abscess. Of the total number of patients discharged from our institution with these diagnoses, these patients represent 7% of all patients with discitis/osteomyelitis, 35% of patients with spinal TB and 5.5% of patients with epidural abscess. In the eight patients with disc discitis/osteomyelitis, the mean WBC was 8.4, mean absolute lymphocyte count 1,910 and mean CD4 count 339.6. Blood cultures were positive in one of six patients, and a biopsy/surgical specimen was positive in three of six patients. The organism identified in these patients was Staphylococcus aureus (sensitive to oxacillin). The remainder of these patients had positive findings on magnetic resonance imaging or nuclear medicine studies. All eight patients had clinical resolution of infection after 6 to 12 weeks of appropriate antibiotics. In contrast, in the six patients with spinal TB the mean WBC was 10.34, mean absolute lymphocyte count 823 (p=.007) and mean CD4 count 57.2 (p=.003). One of the six patients died during the admission. All were treated with antituberculosis medication protocols. The three patients with epidural abscesses had a mean WBC of 16.17, mean absolute lymphocyte count of 913.3 (p=.007) and mean CD4 count of 20.67 (p=.004). Two of three patients had a computed tomography–guided biopsy. The other was diagnosed by imaging and a positive blood culture. The two biopsies grew Nocardia species, and both of these patients died during the admission. The other patient had Group A streptococcus and was treated with a third-generation intravenous cephalosporin for 6 weeks with clinical improvement. There was no significant difference between the groups with regard to age, gender, race, HIV risk factor or length of hospital stay.Conclusion: Spinal infections in patients with HIV at our institution occur at a rate of 0.095%. This is more than the incidence in the general population but much less then originally suspected. Discitis/osteomyelitis occurs in the HIV patient with a mild to moderate decrease in the CD4 count. These patients would fall into the Center for Disease Control (CDC) class 2 (of 3) classification. The organism identified is consistent with that seen in the general population (S aureus), and the disease responds to appropriate antibiotics. Patients with markedly decreased CD4 counts (CDC class 3) were found to have spinal TB, and patients with the lowest CD4 counts developed epidural abscesses with more malignant species. The three in-hospital deaths occurred in the latter two groups. Although the CD4 count can be used as a predictor of the clinical course of the HIV patient with spinal infection, the identification of the organism still remains paramount in the treatment of this complex patient population.

The clinical profile of end-stage AIDS in the era of highly active antiretroviral therapy.

The purpose of this study was to describe the clinical profile of end-stage acquired immune deficiency syndrome (AIDS) since the advent of highly active antiretroviral therapy (HAART). A cross-sectional examination of human immunodeficiency virus (HIV)-infected patients who attended a public HIV outpatient clinic and died between 1996 and 2001 was conducted (n = 669). All clinical and demographic data were collected from the Centers for Disease Control (CDC) Adult Spectrum of Disease database. The prevalence of first-time acquisition of AIDS-defining conditions 12 months before death were evaluated. The prevalence of renal disease, hepatic disease and substance use were also evaluated. The majority of the patients were 35 years old or older, male, African American and HAART-experienced. The six AIDS-defining conditions with the highest percentages of first-time acquisition in the last 12 months of life were HIV dementia (91.8%), progressive multifocal leukoencephalopathy (PML) (91.7%), wasting (90.9%), Mycobacterium avium complex infection (MAC) (80.0%), lymphoma (78.6%), and cytomegalovirus infection (CMV) (78.1%). Forty-four percent of the patients were diagnosed with at least one of these six conditions 12 months before death. More than one third of the patients had renal or hepatic failure, injecting drug use (IDU) as the HIV risk factor, and history of substance use. AIDS-defining conditions continue to have an impact on mortality, especially the neurologic conditions and wasting. However, other conditions, such as renal and hepatic disease, are becoming important causes of mortality because the HIV-infected population now includes more drug users, and HIV-infected patients are surviving for longer periods. These results should help clinicians better time the discussion of end-stage options and improve the patient's quality of life.

Autopsy findings in a human immunodeficiency virus-infected population over 2 decades: influences of gender, ethnicity, risk factors, and time.

To examine autopsy pathology in an urban population infected with the human immunodeficiency virus (HIV) and to determine if age at death and disease frequencies are associated with gender, HIV risk factors, ethnicity, and therapeutic era. Retrospective analysis of autopsy data from 394 HIV-infected adults. The population was divided into 3 therapeutic eras for analysis: group A, 1979-1986; group B, 1987-1995; and group C, 1996-2000. Women died at significantly younger ages than men (mean +/- SEM age, 38.9 +/- 1.0 years vs 42.5 +/- 0.64 years), even after adjustment for risk factors, ethnicity, and therapeutic era. This age discrepancy occurred despite a lower prevalence of arteriosclerosis, cachexia, and hepatitis B in women and no significant differences in the frequencies of other infectious diseases. Whites had a longer survival than patients of other ethnicities (mean age at death, 44.7 +/- 1.2 years for whites, 39.9 +/- 0.80 years for blacks, and 41.3 +/- 0.87 years for Hispanic individuals). Renal, cardiac, and splenic pathologies, Mycobacterium avium-intracellulare (MAI) infection, and cachexia were more common in blacks than in whites and/or Hispanic individuals, and cytomegalovirus and systemic lymphoma were more common in whites and Hispanic individuals than in blacks. Diseases associated with intravenous drug use were hepatitis C, cirrhosis, and tuberculosis; those with all sexual risk factors, cytomegalovirus infection, herpes simplex virus infection, and Pneumocystis carinii pneumonia; and those with homosexual risk, Kaposi sarcoma and MAI infection. The prevalence of many disease entities changed over time: compared with the other groups, group C had lower prevalences of many viral and fungal illnesses, MAI infection, systemic lymphoma, cachexia, and Kaposi sarcoma and higher prevalences of hepatitis, cirrhosis, arteriosclerosis, staphylococcal and streptococcal infections, and traumatic lesions. When the data were adjusted for changing demographic and risk composition, the only significant changes in disease frequency for period C were decreased prevalences of PCP and Kaposi sarcoma and increased prevalences of cirrhosis and arteriosclerosis. Significant gender- and ethnicity-related differences in age of death occurred in this HIV-infected population, and these differences were not explained by the frequencies of diseases. The lower prevalences of PCP and Kaposi sarcoma in group C are likely a reflection of the impact of potent therapies on causes of mortality. The higher prevalences of cirrhosis and arteriosclerosis suggest that entities not targeted by antiretroviral reconstitution of immunity will play an increasingly important role in HIV-related mortality in the future.