Young HIV Patients Research Articles

Cardiovascular Risk Assessment in Young HIV Patients from Constanţa County, Romania, Using Cardiovascular Risk Scores

Abstract HIV/AIDS remains one of the greatest global health challenges, affecting millions of people worldwide. Realizing the seriousness of the situation, various strategies were designed and implemented, aiming to mitigate the impact of the disease and, finally, to eradicate it. Although these strategies have produced remarkable progress over time, a new category is emerging, the aging population with HIV. Cardiovascular pathology is increasingly common in young population with HIV infection, aged due to the presence of this virus and the antiretroviral therapy instituted for decades. Cardiovascular risk scores are useful for the general population, but for HIV patients, they need to be adapted. The aim of this study was to evaluate cardiovascular risk scores used in HIV patients from Dobrogea regional center, in the records of the Clinical Hospital of Infectious Diseases in Constanța.

Image du corps et estime de soi des patients VIH au Gabon

ObjectiveThe study proposes the analysis of the relationship between body image, self-esteem and body shame (dependent variables) in HIV patients according to their age, gender, level of education, HIV status and year of their HIV screening. We also wanted to see how independent variables (gender and age) affect self-esteem, body image and body shame. MethodsParticipants included 158 HIV patients (men and women) who completed a battery of self-report measures: the Rosenberg Self-Esteem Scale (1965), the Bruchon-Schweitzer Body Image Scale (BIS) (1990), and the body shame subscale from the Shame Experience Scale (ESS) by Andrews et al. (2002). ResultsThe first hypothesis, which tests the link between self-esteem, body image and body shame and the sociodemographic variables (age, gender, level of education, HIV status and year of screening), showed a significant relationship among Gabonese HIV patients. The second hypothesis, which evaluates the influence of age and gender on all our dependent variables (self-esteem, body image and body shame), indicated that women are no more likely to express more body dissatisfaction and shame about their bodies and their level of self-esteem is no lower than that of men. Finally, an intergroup comparison demonstrated that self-esteem is lower among youth in certain age groups. ConclusionThere are significant links between self-esteem, body image and body shame with a lower level of self-esteem in young HIV patients. For clinicians involved in the management of HIV patients, knowledge of the level of self-esteem, body dissatisfaction and body shame would allow for the development of appropriate care and therapeutic intervention goals (therapeutic group, self-efficacy group).

Inhibitory control is associated with medication adherence in young HIV patients without comorbidities

Objective In the present study we evaluated the incremental contribution of executive cognition (EC) subprocesses to antiretroviral medication adherence. Method A comprehensive EC test battery assessing updating/working memory, mental flexibility, and inhibitory control, along with measures assessing non-executive cognitive functions were completed by 100 individuals with HIV. Medication adherence was determined via a visual analogue self-report scale and the Medication Adherence Questionnaire. Potential predictors, including demographic and clinical characteristics and neuropsychological performances on EC and other cognitive tasks were regressed to medication adherence. Predictive variables related to executive processes were added in the final block of the hierarchical regression model in order to assess their incremental predictive ability on medication adherence. Results 23% of the variance in the visual analogue scale was explained by treatment complexity, memory and EC performance. A measure of inhibitory control, in particular, predicted self-reported medication adherence above and beyond demographic, clinical and other cognitive factors. Conclusions The contribution of EC to self-reported medication adherence in young seropositive adults was limited, but inhibitory control was associated with proper medication management above and beyond demographic, clinical and other cognitive functions.

Periodontitis and Cytomegalovirus Associate With Atherosclerosis Among HIV Patients After 5 Years on ART.

Atherosclerosis has been linked with periodontitis in the general population and with persistent immune activation and a high burden of cytomegalovirus (CMV) in HIV patients responding to antiretroviral therapy (ART). Here, we assess risk factors for cardiovascular changes in younger HIV patients representative of patient populations in Asia. HIV-infected adults (n = 82) with <200 CD4 T-cells/μl were examined as they began ART at Cipto Mangunkusumo Hospital, Jakarta, and after 3 months. 32 patients were re-assessed after 5 years, alongside 32 age-matched healthy controls. We assessed the community periodontal index of treatment needs, carotid -thickness (cIMT), plasma markers of immune activation (using commercial enzyme-linked immunosorbent assay) and CMV antibodies by in-house enzyme-linked immunosorbent assay. Periodontitis persisted in 16/32 patients after 5 years and was potentiated by greater age (P = 0.03) and poor oral hygiene (P = 0.05), with no effect of smoking, pulmonary tuberculosis, oral candidiasis, or low CD4 T-cell counts (P > 0.05). After 5 years on ART, right and left cIMT were greater in HIV patients with periodontitis (P = 0.02, 0.006, respectively). Moreover, cIMT values were higher in patients with periodontitis (P = 0.05-0.01) than in equivalent controls. Simple linear regressions showed that patients with periodontitis had greater right (P = 0.01) and left (P = 0.004) cIMT than those without periodontitis. Multiple linear regressions showed that periodontitis and CMV antibody levels optimally predicted poor right and left cIMT (Adjusted R = 0.36, P = 0.0013; Adjusted R = 0.40, P = 0.001, respectively). Our data identify periodontitis and CMV as independent predictors of atherosclerosis in young adult HIV patients.

Altered Brain Function in Young HIV Patients with Syphilis Infection: A Voxel-Wise Degree Centrality Analysis.

ObjectiveThis study assessed the possible effect of syphilis co-infection in the brain function in young HIV patients by using voxel-wise degree centrality (DC) analysis.MethodsForty-four syphilis-co-infected HIV patients (HIV+/syphilis+), 45 HIV patients without syphilis history (HIV+/syphilis-) and 43 matched healthy controls (HC) underwent resting-state fMRI examinations. Laboratory tests and a battery of neuropsychological tests were performed before each MRI examination. One-way ANOVA was used to compare the differences of DC among the three groups. The correlations between MRI metrics and laboratory/neuropsychological tests in each patient’s group were performed by Pearson correlation analysis.ResultsCompared with HIV+/syphilis-, worse performance in complex motor skills was found in HIV+/syphilis+. Compared with HC, HIV+/syphilis+ and HIV+/syphilis- groups showed attenuated DC in the right orbital frontal cortex and increased DC in the left parietal/temporal cortex. Besides, we also found increased DC in the left inferior frontal cortex and bilateral posterior cingulated cortex/precuneus in HIV+/syphilis+ compared with HC. Moreover, compared with HIV+/syphilis-, HIV+/syphilis+ displayed decreased DC in the left middle occipital cortex. Additionally, in HIV+/syphilis+ group, the mean z value of DC was correlated to the CD4+ cell counts and the learning and delayed recall score.ConclusionSyphilis co-infection might be related to more brain functional reorganization in young HIV patients which could be reflected by DC value.

639. Indoleamine 2,3 Dioxygenase, Age, and Chronic Immune Activation in HIV Patients

BackgroundImmune activation complicates HIV despite antiretroviral therapy (ART). Indoleamine 2,3 dioxygenase (IDO) catabolizes tryptophan (T) to kynurenine (K), regulating immune activity. IDO activity increases in HIV patients and non-HIV patients with age. This study examines the relationship of IDO activity, bacterial translocation, and ageing in HIV patients on ART. We hypothesize that increased IDO activity caused by bacterial translocation is a factor in inflammation during aging. Methods. Samples and data from virologically suppressed HIV patients on ART in specific age strata were obtained from the Centers for AIDS Research Network of Integrated Clinical Systems. Samples and data from age and sex-matched healthy controls were obtained from the Multicenter AIDS Cohort Study and the Women’s Interagency HIV Study. The ratio of K to T (K/T) and neopterin were used as indicators of inflammation; 16S ribosomal DNA (16S rDNA) and lipopolysaccharide (LPS) served as markers of bacterial translocation. Log transformation, chi-square tests, t-tests with Satterthwaite adjustment for continuous data, ANOVA, and ANCOVA homogeneity of slopes model were used. Results. Samples and data from 205 HIV patients and 99 matched controls were analyzed. HIV patients had higher K/T values across all ages. Younger HIV patients had greater K/T values than older healthy controls. Age, sex or race was not associated with differences in K/T. Current CD4 count or CD4 nadir had no association with K/T ratio. For HIV patients, there was an inverse relationship between LPS detection and K/T. For controls, there was no association between LPS and K/T. There was no association between PCR detection of 16S rDNA and K/T ratio in HIV patients or controls. Both groups had positive association between K/T ratio and neopterin. Conclusion. HIV patients have elevated K/T, even at younger ages, despite virologic control. The main hypothesis that K/T increases with advancing age was not supported in this cohort. Also, unlike other published literature, CD4 nadir, LPS, and 16S rDNA did not correlate with K/T ratio. This study suggests there may be an alternative driver of immune inflammation in well-controlled HIV patients other than bacterial translocation.Figure 2.Age and K/T ratio.Disclosures A. Mellor, NewLink Genetics: Consultant, Consulting fee and Licensing agreement or royalty.

Characterization of Natural Killer Cells in HIV Patients Beginning Therapy with a High Burden of Cytomegalovirus

ABSTRACTBackground: Active infections with cytomegalovirus (CMV) increase NK cell expression of the inhibitory receptor LIR-1 and the activating receptor NKG2C in transplant recipients. However, the effects of CMV on NK cells are different in HIV patients stable on antiretroviral therapy (ART) and have not been analyzed in young HIV patients beginning ART.Methodology: We followed a cohort of 78 Indonesian HIV patients beginning ART. CMV antibodies were measured in plasma before ART (baseline), and after 1, 3, 6, and 12 months. CMV DNA was sought in blood granulocytes at baseline by quantitative PCR assay and a deletion in the NKG2C gene was identified by PCR. NK cell profiles were monitored by flow cytometry in 19 patients stratified by the presence of CMV DNA. Healthy controls (n = 17) were assessed once.Results: All 78 patients were CMV seropositive and 41 had detectable CMV DNA. CMV DNA+ patients had higher proportions of total NK cells and CD16+ NK cells at baseline, but similar expression of LIR-1 and NKp30 on NK cells on ART. However, levels of CMV antibody were inversely related to median LIR-1 expression on NK cells. A dramatic elevation in cells expressing NKG2C was restricted to CMV DNA+ patients heterozygous for the NKG2C deletion. Patients with High NKG2C expression had lower levels of CMV antibodies.Conclusion: A subpopulation of NK cells expressing NKG2C was induced by CMV replication in HIV patients heterozygous for a deletion in this gene. Individuals with an abundant NKG2C+ and LIR-1+ NK cells displayed lower levels of CMV reactive antibody.

Active and Persistent Cytomegalovirus Infections Affect T Cells in Young Adult HIV Patients Commencing Antiretroviral Therapy.

Altered T cell profiles have been linked with metrics of persistent cytomegalovirus (CMV) infections in healthy aging and older HIV patients stable on antiretroviral therapy (ART). In this study, we use CMV DNA to identify active infections, and levels of CMV-reactive antibody to assess the persistent burden of CMV in a longitudinal study of 78 young adult patients beginning ART in Jakarta, Indonesia, with <200 CD4 T cells/μL. CMV antibodies, inflammatory markers (C-reactive protein [CRP], soluble interferon-α/β receptor) and T cell phenotypes were assessed before ART (V0) and after 1, 3, 6, and 12 months (V1-V12). CMV DNA was detected in 41 patients (52%) at V0, irrespective of CD4 T cell counts, gender, age, or plasma HIV RNA. CMV DNA+ patients had higher levels of antibody reactive with CMV Immediate Early 1 (IE-1) at V0 and V12 (p = 0.04), and with CMV lysate at V12 (p = 0.01). Detectable CMV DNA did not align with inflammatory markers, but associated with lower CD4/CD8 ratios until V3. CMV antibody levels correlated inversely with proportions of naive CD4 and CD8 T cells, and directly with proportions of CD57+ and activated memory T cells (CD3+ CD45RA-) after 3-12 months on ART. Overall, active CMV replication is common in HIV patients beginning ART in Indonesia and associates with low CD4/CD8 ratios. Elevated levels of CMV-reactive antibody measured on ART also mark a depletion of naive T cells, accumulation of memory T cells, and may be a stable metric of the burden of CMV.

Human Immunodeficiency Virus disease and cardiac surgery – where are we?

Uncertainties concerning the effects of cardiopulmonary bypass, outcome and possibility of operator injury slowed progress in cardiac surgery in the HIV-infected patient. Severely ill patients, some with AIDS and others probably with AIDS, formed the basis of early reports; it was shown they could be taken through surgery satisfactorily. Following the advent of antiretroviral monotherapy – zidovudine, an NRTI – in 1987, and dual therapy in the early 1990s with NRTIs, the addition of protease inhibitors (PI) in 1995, although a double-edged sword, led to triple therapy/HAART, (2 NRTIs and a PI) and startling improvement in morbidity and mortality in markedly compromised HIV patients. Yet, it was only in 2003 when sizeable reports carrying ARV usage began to emerge. Intravenous drug addiction causing left-sided valvular heart disease was initially responsible for most cases, but there was now an increase in coronary artery disease (CAD) in young patients, blamed partly on lipid disturbances caused by PI. With an ARV rollout in South Africa delayed to 2004, and PIs only used in second line therapy in State-administered treatment, the increase in coronary artery disease has not been noted. The need for surgery in pericardial disease is rare. Paediatric cardiac surgery has been rarely reported, but is locally carried out; a new approach to medical management of these children should lead to more frequent surgery. Heart transplantation lags far behind solid organ transplantation, but there are indications that it will be more readily accepted. Certain vascular pathologies appear to be peculiar to HIV, with the virus itself being able to enter vessel walls with evolution of vascular disease. PIs would appear to accelerate coronary artery disease, as seen in younger HIV patients, who develop abnormal lipid profi les. The approach to cardiac surgery in most cardiac teaching units is looked at. Many answers have been found, but new issues have also arisen, as in relation to ARV’s and CAD. Most importantly, attitudes are changing: some would accept selected patients with AIDS not receiving ARVs. Very good results have followed surgery in patients who have suffered AIDS defining conditions but are stable on ARVs.

Text Message Reminder-Recall to Increase HPV Immunization in Young HIV-1-Infected Patients.

HIV infected patients have higher rates of HPV infection, worse disease progression, increase severity of disease, and are at higher risk for intraepithelial neoplasia and cancer than their HIV negative counterparts. We conducted a yearlong pilot project to evaluate the impact of text message HPV immunization reminder-recall in young HIV-1 positive patients in a large urban academic HIV clinic. We found that text message reminder-recall improved HPV immunization uptake in a young, primarily black and un- or under-insured HIV-1 infected patients. As communication by texting is characteristic of teens and young adults in the general population, text message reminder-recalls should be considered a viable option to improve vaccination rates among young HIV patients.

CD4+/CD8+ ratio, age, and risk of serious noncommunicable diseases in HIV-infected adults on antiretroviral therapy.

In virologically suppressed HIV-infected adults, noncommunicable diseases (NCDs) have been associated with immune senescence and low CD4/CD8 lymphocyte ratio. Age differences in the relationship between CD4/CD8 ratio and NCDs have not been described. Observational cohort study. We assessed CD4/CD8 ratio and incident NCDs (cardiovascular, cancer, liver, and renal diseases) in HIV-infected adults started on antiretroviral therapy between 1998 and 2012. Study inclusion began once patients maintained virologic suppression for 12 months (defined as baseline). We examined age and baseline CD4/CD8 ratio and used Cox proportional hazard models to assess baseline CD4/CD8 ratio and NCDs. This study included 2006 patients. Low baseline CD4/CD8 ratio was associated with older age, male sex, and low CD4 lymphocyte counts. In models adjusting for CD4 lymphocyte count, CD4/CD8 ratio was inversely associated with age (P < 0.01). Among all patients, 182 had incident NCDs, including 46 with coronary artery disease (CAD) events. CD4/CD8 ratio was inversely associated with risk of CAD events [adjusted HR per 0.1 increase in CD4/CD8 ratio = 0.87, 95% confidence interval (CI): 0.76-0.99, P = 0.03]. This association was driven by those under age 50 years (adjusted HR 0.83 [0.70-0.97], P = 0.02) vs. those over age 50 years (adjusted HR = 0.96 [0.79-1.18], P = 0.71). CD4/CD8 ratio was not significantly associated with incident noncardiac NCDs. Higher CD4/CD8 ratio after 1 year of HIV virologic suppression was independently predictive of decreased CAD risk, particularly among younger adults. Advanced immune senescence may contribute to CAD events in younger HIV patients on antiretroviral therapy.

Receipt of clinical and prevention services, clinical outcomes, and sexual risk behaviors among HIV-infected young adults in care in the United States

ABSTRACTWe describe receipt of clinical and prevention services, clinical outcomes, and sexual risk behaviors among young adult HIV patients in the United States during 2009–2013, using a sample designed to produce nationally representative estimates. Compared with older HIV patients, proportionately more young adults received provider-delivered prevention services and reported sexual risk behaviors. Young adults had similar care patterns as older HIV patients, but were less likely to have or adhere to an antiretroviral therapy prescription and achieve viral suppression. These estimates establish a national baseline from which to monitor changes in clinical outcomes and transmission behaviors among young HIV-infected adults.

Acute Spontaneous Coronary Artery Thrombosis as Initial Presentation of HIV Infection in a Young Man.

Introduction. The presentation of acute coronary syndrome (ACS) in young HIV patients may be atypical with different pathophysiological and clinical features. Acute coronary thrombosis, as a presentation of acute coronary syndrome in young patients with HIV, raises diagnostic and treatment challenges. Case Presentation. We describe a case of a 33-year-old African man, without traditional atherosclerotic risk factors, who presented with chest pain of acute onset. Emergent coronary angiography revealed extensive thrombus in the left anterior descending coronary artery with no evidence of atherosclerosis in this or other coronary vessels. Plaque and/or thrombus prolapse through the stent was noted following percutaneous coronary intervention (PCI). Resolution of chest pain and improvement in ST-segment elevation was noted after the procedure. A diagnosis of HIV infection was made during the workup for HIV infection. Conclusion. In young patients without traditional risk factors, HIV infection is a possible etiological factor for spontaneous coronary artery thrombosis. Percutaneous coronary intervention in patients with this presentation may be compounded with atherothrombotic complications. The likely pathophysiological pathway is superficial endothelial cell denudation as a result of chronic inflammation and immune activation.

Serotype distribution and antibiotic susceptibility of Streptococcus pneumoniae strains carried by children infected with human immunodeficiency virus.

BackgroundWe studied the serotype distribution and antibiotic susceptibility of Streptococcus pneumoniae isolates carried by children infected with HIV in Jakarta, Indonesia.MethodsNasopharyngeal swabs were collected from 90 HIV infected children aged 4 to 144 months. S. pneumoniae was identified by conventional and molecular methods. Serotyping was performed with sequential multiplex PCR and antibiotic susceptibility with the disk diffusion method.ResultsWe identified S. pneumoniae carriage in 41 children (46%). Serotype 19F was most common among 42 cultured strains (19%) followed by 19A and 6A/B (10% each), and 23F (7%). Most isolates were susceptible to chloramphenicol (86%), followed by clindamycin (79%), erythromycin (76%), tetracycline (43%), and sulphamethoxazole/trimethoprim (41%). Resistance to penicillin was most common with only 33% of strains being susceptible. Strains of serotypes targeted by the 13-valent pneumococcal conjugate polysaccharide vaccine (PCV13) were more likely to be multidrug resistant (13 of 25 or 52%) compared to non-PCV13 serotype isolates (3 of 17 or 18%; Fisher exact test p = 0.05).ConclusionOur study provides insight into the epidemiology of pneumococcal carriage in young HIV patients in Indonesia. These findings may facilitate potential preventive strategies that target invasive pneumococcal disease in Indonesia.

Clinical characteristics and antiretroviral treatment of older HIV-infected patients.

The number of Human Immunodeficiency Virus (HIV) patients aged 50 years or over is growing year on year, due to both late diagnoses and the chronicity of the illness. This increase is a new phenomenon. To describe the clinical and epidemiological characteristics of the older HIV infected population and determine if there are differences in antiretroviral treatment between younger and older patients. This study was conducted in the outpatient hospital pharmacy service of a University Hospital in Spain. A descriptive study involving HIV infected patients aged 50 years or older who received ambulatory antiretroviral therapy between January and December 2011. Variables related to HIV and to antiretroviral therapy were collected. A comparison of antiretroviral drugs used was made with the populations older and younger than 50 years. Antiretroviral therapy differences between older and younger HIV-patients. 130 patients (20% of the antiretroviral treated patients) were 50 or over and 77% of these was aged between 50 and 59. At the time of diagnosis, 50% suffered an advanced state of disease. At the end of the study period, 58% had CD4 lymphocyte levels of over 500 cells/mm(3) and 90% had an undetectable viral load. The antiretroviral therapy of the older group that was based on protease inhibitors was used in the 51.5% of the patients compared with 54.4% in the younger group. The figures for nonnucleoside reverse transcriptase inhibitors based therapy were 43.8 and 39.8%, respectively. The older population used treatments that included tenofovir (56.9 vs. 64.8%, p = 0.105) less frequently and used more treatments that included abacavir (26.9 vs. 19.1%, p = 0.054) than the under 50's. Half the older HIV-infected patients were diagnosed with an advanced disease and the majority showed a positive response to antiretroviral therapy. There are no statistically significant differences between the frequency of antiretroviral therapy use in older and younger HIV-patients, although older HIV-patients has less often used treatments with tenofovir and more often used treatments with abacavir.

Prevalence of Adult Attention Deficit Hyperactivity Disorder and its Correlates among Recently Diagnosed Young Adult Males with HIV

A majority of children with symptoms of Attention Deficit Hyperactivity Disorder (ADHD) from early childhood continue to demonstrate notable ADHD symptoms throughout life. ADHD-associated impulsivity, in adults, has been found to be a predictor of unstable interpersonal relationships and high risk sexual behavior. This study was undertaken to determine the prevalence of adult ADHD in recently diagnosed young male HIV patients. 100 young adult males who were diagnosed with HIV less than a year ago were recruited after an informed consent and were administered the following questionnaires-socio-demographic questionnaire with details of HIV diagnosis, HIV High Risk Behavior Questionnaire (HRBS) to measure High risk sexual behaviors, MINI neuropsychiatric Interview 6.0 to rule out psychiatric co-morbidities, Mini Mental State Examination (MMSE) to rule out major cognitive impairment, Adult ADHD Self Report scale (ASRS) v1.1 to screen for ADHD in adulthood. ADHD-rating scale was administered to parent/ informant to screen for childhood ADHD. Statistical analyses were done using SPSS v 17.0. The prevalence of Adult ADHD in our sample was 20%. 94% of subjects were on Highly Active Anti-Retroviral Therapy (HAART). Adherence to HAART was comparatively lesser in the ADHD group which was statistically significant (p=0.014). Substance use was significantly more in the ADHD group (p=0.03). People with ADHD had significantly higher High Risk sexual behavior than those without ADHD (p<0.001). Hence, these findings suggest that ADHD may contribute to high risk sexual behavior and thereby also the risk of contracting HIV. Future research on a larger population will provide more conclusive evidence. For now, health promotion and specific protection with greater emphasis in this vulnerable population of adult ADHD would be warranted in preventing HIV.

Proximal Tubule Function and Free Water Clearance: Comparison between Healthy Elderly and Young HIV+ Patients

In previous studies it was documented that proximal tubule sodium reabsorption capability was preserved in healthy elderly, while Thick Ascending Loop of Henle (TALH) one was reduced. Aim: Since, it has also been documented that senile changes are accelerated in HIV patients, we performed a prospective study in order to evaluate if there was a significant difference in proximal and TALH function between healthy elderly and HIV patients. Methods: Proximal and TALH was analyzed by performing hyposaline infusion test in 10 young (≥ 18-≤ 40 years old) HIV volunteers under treatment with tenofovir, free of viral charge, and normal renal function: serum creatinine, urinary sediment, and renal ultrasound), with the control group made up of 10 healthy old volunteers (≥ 65 years old). Results: During the test, it was observed that the HIV group had a significant reduction of natremia (HIV: 133 ± 1 mmol/l vs. healthy elderly: 139 ± 1 mmol/l, p=0.03), serum osmolarity (HIV: 276 ± 4 mOsm/l vs. elderly: 288 ± 3 mOsm/l, p=0.03) and free water clearance (HIV: 3.5 ± 3 ml/min/1.73 m² vs. elderly: 5 ± 8 ml/min/1.73 m², p ≤ 0.01). Besides, HIV patients showed an inadequate and significant increase in their urinary tonicity in comparison with the healthy elderly group: HIV: 170 ± 18 mOsm/l vs. elderly: 90 ± 10, p ≤ 0.01. Regarding proximal tubular function, it was found that it was preserved in both groups. Conclusion: Proximal tubule sodium reabsorption was normal, while free water clearance was significantly reduced in young HIV patients in comparison with healthy elderly volunteers.

Comparison of Ischemic Stroke Incidence in HIV-Infected and Non–HIV-Infected Patients in a US Health Care System

Cardiovascular disease is increased among HIV-infected patients, but little is known regarding ischemic stroke rates. We sought to compare stroke rates and determine stroke risk factors in HIV-infected versus non-HIV-infected patients. An HIV cohort and matched non-HIV comparator cohort seen between 1996 and 2009 were identified from a Boston health care system. The primary endpoint was ischemic stroke, defined using International Classification of Diseases (ICD) codes. Unadjusted stroke incidence rates were calculated. Cox proportional hazards modeling was used to determine adjusted hazard ratios (HRs). The incidence rate of ischemic stroke was 5.27 per 1000 person-years in HIV-infected compared with 3.75 in non-HIV-infected patients, with an unadjusted HR of 1.40 [95% confidence interval (CI): 1.17 to 1.69, P < 0.001]. HIV remained an independent predictor of stroke after controlling for demographics and stroke risk factors (HR: 1.21, 95% CI: 1.01 to 1.46, P = 0.043). The relative increase in stroke rates (HIV vs. non-HIV) was significantly higher in younger HIV patients (incidence rate ratio: 4.42, 95% CI: 1.56 to 11.09, age 18-29; 2.96, 1.69-4.96, age: 30-39; 1.53, 1.06-2.17, age: 40-49), and in women [HR: 2.16 (95% CI: 1.53 to 3.04) for women vs. HR: 1.18 (95% CI: 0.95 to 1.47) for men]. Among HIV patients, increased HIV RNA (HR: 1.10, 95% CI: 1.04 to 1.17, P = 0.001) was associated with an increased risk of stroke. Stroke rates were increased among HIV-infected patients, independent of common stroke risk factors, particularly among young patients and women.

Hip and knee replacement in the HIV positive patient.

Arthroplasty is used to relieve pain associated with degenerative or inflammatory joint disease, some post-traumatic joint problems, and avascular necrosis. Avascular necrosis, inflammatory and post-traumatic problems are seen on a regular basis in areas of high HIV seroprevalence. Degenerative arthritis is rare in younger HIV patients, however. Historically the only group of HIV patients in which arthroplasty has been common is that which received contaminated factor VIII transfusions in the 1980's. Haemophiliacs get a haemophilic arthropathy from repeated bleeds into joints and so is an additional complication. Much of the previous literature on this topic has focused on haemophiliac patients. This review examines the success of arthroplasty in HIV positive patients, with an emphasis on non-haemophiliac patients. We conclude that arthroplasty can be a safe procedure for HIV positive individuals if the surgery is carried out in good conditions, and early results are encouraging.

Salvage Therapy for Refractory Aids-Related Primary Central Nervous System Lymphoma

A 27-year-old male patient presented with speech disorders and multiple brain masses on MRI evaluation. He tested positive for HIV. A sterotactic biopsy diagnosed primary central nervous system lymphoma (diffuse large B-cell lymphoma). After two cycles of high-dose metotrexate (HD-MTX-)-based chemotherapy, the tumor progressed. He underwent whole brain radiotherapy achieving complete response. Six cycles of consolidating immunochemotherapy with rituximab-temozolomide were administered after radiation. Forty-three months after remission, he has not recurred and his neurological status is optimal. Younger HIV patients with refractory PCNSL and preserved immune function can face salvage therapy successfully achieving long term remissions with no remarkable neurotoxicity.