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Lung cancer is the leading cause of death among non-acquired immunodeficiency syndrome (AIDS)-defining malignancies. Because highly active antiretroviral therapy (HAART) has improved the survival of patients with human immunodeficiency virus (HIV), the authors evaluated lung cancer outcomes in the HAART era. HIV-positive patients who were diagnosed with lung cancer at the authors' institution during the HAART era (1995-2008) were analyzed. Patient charts were reviewed for clinical and laboratory data. The CD4 count at diagnosis was treated as a continuous variable and subcategorized into distinct variables with 3 cutoff points (50 cells/mL, 200 cells/mL, and 500 cells/mL). Pearson correlation coefficients were estimated for each covariate studied. Survival was determined by using the Kaplan-Meier method. Of 80 patients, 73 had nonsmall cell lung cancer. Baseline characteristics were as follows: median patient age, 52 years; male, 80%; African Americans, 84%; injection drug users, 25%; smokers, 100%; and previous exposure to antiretroviral agents, 55%. At the time of cancer diagnosis, the mean CD4 count was 304 cells/mL, and the mean viral load was 82,420 copies/mL. The latency between HIV diagnosis and lung cancer diagnosis was significantly shorter among women (4.1 years vs 7.7 years; P = .02), and 71% of patients received anticancer therapy. The 1-year and 3-year survival rates for stage IIIB/IV were 25% and 0%, respectively. Grade 3/4 toxicities occurred in 60% of patients who received chemoradiation versus 36% of patients who received chemotherapy. Cancer-related survival was better for patients with CD4 counts >200 cells/mL (P = .0298) and >500 cells/mL (P = .0076). The latency from diagnosis of HIV to lung cancer was significantly shorter for women. Although outcomes for patients with lung cancer who have HIV remain poor, a high CD4 count was associated with improved lung cancer-related survival.

To assess associations between the timing of hepatitis B virus (HBV) immunization relative to human immunodeficiency virus (HIV) diagnosis and vaccine effectiveness, US Military HIV Natural History Study cohort participants without HBV infection at the time of HIV diagnosis were grouped by vaccination status, retrospectively followed from HIV diagnosis for incident HBV infection, and compared using Cox proportional hazards models. A positive vaccine response was defined as hepatitis B surface antibody level ≥ 10 IU/L. Of 1,877 participants enrolled between 1989 and 2008, 441 (23%) were vaccinated prior to HIV diagnosis. Eighty percent of those who received vaccine doses only before HIV diagnosis had a positive vaccine response, compared with 66% of those who received doses both before and after HIV and 41% of those who received doses only after HIV (P < 0.01 for both compared with persons vaccinated before HIV only). Compared with the unvaccinated, persons vaccinated only before HIV had reduced risk of HBV infection after HIV diagnosis (hazard ratio = 0.38, 95% confidence interval: 0.20, 0.75). No reduction in HBV infection risk was observed for other vaccination groups. These data suggest that completion of the vaccine series prior to HIV infection may be the optimal strategy for preventing this significant comorbid infection in HIV-infected persons.

Infection with the human immunodeficiency virus (HIV) affects over 1.3 million people is in the United States and over 35 million people worldwide.[1] Despite improvements in treatment, HIV is still associated with increased morbidity and mortality. While infectious complications of HIV and the Acquired Immunodeficiency Syndrome (AIDS) have decreased, non-communicable diseases such as cardiovascular disease, chronic obstructive pulmonary disease, end-stage renal disease, and diabetes are becoming more common in HIV-infected persons as they are living longer with highly active antiretroviral therapy (HAART).[2] The impact of HAART has also been seen in the intensive care unit (ICU) in both the diagnoses seen and their prognoses. In the early AIDS era, mortality for HIV-infected persons admitted to the ICU was very high, and it was often seen as futile to admit these patients to the ICU.[3, 4] HAART, in combination with HIV-specific improvements in care such as corticosteroids for Pneumocystis pneumonia and advances in general ICU care such as low tidal volume ventilation, has resulted in an overall improvement in survival of HIV-infected persons admitted to the ICU.[5] Causes of ICU admission have also shifted with a decrease in AIDS-associated diagnoses such as Pneumocystis pneumonia; however, respiratory failure has remained the most common cause of ICU admission, and sepsis has increased.[5-8] Additionally, with effective treatment, HIV-infected persons are living longer. In 2009, 36.2% of HIV-infected persons who received medical care were over 50 years old, and this estimate is expected to go over 50% in 2015.[9, 10] Diagnoses common in the ICU setting, such as sepsis, increase drastically with age.[11] Sepsis is also independently associated with worse mortality in HIV-infected persons, even in the era of HAART.[7, 12] Other co-morbid conditions associated with aging with HIV such as cardiovascular disease might also impact mortality in this population. It is unclear if current survival of HIV-infected patients admitted to the ICU with sepsis is as good or worse than HIV-uninfected patients. In this issue of Critical Care Medicine, Cribbs et al. [13] compare baseline characteristics and outcomes in HIV-infected and -uninfected persons admitted to three ICUs in Grady Memorial Hospital with severe sepsis. HIV-infected patients were younger and had a lower body mass index, but they were more likely to have a history of chronic dialysis, pneumonia, infection requiring hospitalization, and sepsis. HIV-infected patients also higher hospital mortality, 50% vs. 38% (p=0.007). This association remained significant when controlling for baseline demographics, history of infections, and other predictors of mortality, including the Acute Physiology and Chronic Health Evaluation (APACHE) II score which was available in a subset of HIV-infected and -uninfected persons. While the primary source of infection was most commonly respiratory in both HIV-infected and -uninfected individuals, respiratory was more often the primary source in HIV-infected, 61% vs. 48% (p=0.002); and HIV-infected persons were less likely to have gram-positive infections (39% vs. 53%, p=0.01), but more likely to have fungal infections such as Pneumocystis, Cryptococcus, and Candida as the primary cause of their sepsis. The difference in outcomes with HIV infection may be related to subtle immune defects even in treated HIV or other underlying factors that remain as unadjusted confounders. A striking finding of the study was that even in a major US city, the population had a low prevalence of HAART use at the time of severe sepsis (22%), and most participants had a CD4 count <=200 (79%). Only 11% of HIV-infected participants were new diagnoses of HIV. The distribution of CD4 count was low, even in those on HAART. It is hard to know how outcomes of severe sepsis in HIV-infected persons well-controlled on HAART might differ from that found in this study and caution should be taken when applying results from this study to different ICU populations. Additionally, while HIV treatment is widely available in the Ponce de Leon Center in Atlanta, Georgia, where most HIV-infected participants in this cohort seek care, there is a disparity in health care coverage that likely confounds the relationship between HIV infection and in-hospital mortality in this study. The study also does not elucidate how longer term outcomes may differ between HIV-infected and -uninfected person after severe sepsis, which may be of even greater divergence considering the pre-morbid conditions and potential differences in access to care. Cribbs et al. show us that outcomes in HIV-infected patients admitted to the ICU with severe sepsis are worse than outcomes in HIV-uninfected patients. These data point out the need to improve HIV care and care delivery, both in the acute intensive care unit setting (awareness of the spectrum of infectious causes) and potentially in chronic HIV care delivery. The study has generated questions worth answering to determine why HIV-infected persons have worse outcomes from severe sepsis.

Human immunodeficiency virus (HIV) prevention interventions for prevention interventions for women include screening, partner notification, promoting condoms, and preexposure prophylaxis (PrEP). Women's risk of acquiring HIV can help guide recommendations. We used data from Louisiana's sexually transmitted infection (STI) and HIV registries to study 13- to 59-year-old women following first diagnosis of syphilis, gonorrhea, or chlamydia during 2000-2015. We measured HIV rates reported subsequent to STI (through 2016). Rates for women without STI were estimated by subtracting women with STI from reported cases and from Census estimates for the population. PrEP cost was estimated as $11 000 per year, and effectiveness estimated as 100%. STIs were syphilis (6574), gonorrhea (64 995), or chlamydia (140 034). These 211 603 women had 1 865 488 person-years of follow-up and 969 HIV diagnoses. Women with no STI had 5186 HIV diagnoses over 24 359 397 person-years. HIV rates diagnosis (per 100 000 person-years) were higher for women after syphilis (177.3), gonorrhea (73.2), or chlamydia (35.4) compared to women with no STI (22.4). Providing PrEP to all women diagnosed with syphilis or gonorrhea would cost $7 371 111 000 and could have prevented 546 HIV diagnoses. Limiting PrEP to 1 year after syphilis or gonorrhea diagnosis would cost $963 847 334, but only 143 HIV diagnoses were within 2 years after a syphilis or gonorrhea diagnosis. Rates of HIV diagnosis were high after women had STI, but not high enough to make PrEP cost-effective for them. Most women diagnosed with HIV did not have previously reported STI.

BackgroundPersons unaware of their human immunodeficiency virus (HIV) infection account for approximately 40% of ongoing transmissions in the United States. Persons are unaware of their infection because of delayed HIV diagnoses that represent substantial missed opportunities to improve health outcomes and prevent HIV transmission.MethodsData from CDC’s National HIV Surveillance System were used to estimate, among persons with HIV infection diagnosed in 2015, the median interval (and range) from infection to diagnosis (diagnosis delay), based on the first CD4 test after HIV diagnosis and a CD4 depletion model indicating disease progression and, among persons living with HIV in 2015, the percentage with undiagnosed infection. Data from CDC’s National HIV Behavioral Surveillance were analyzed to determine the percentage of persons at increased risk for HIV infection who had tested in the past 12 months and who had missed opportunities for testing.ResultsAn estimated 15% of persons living with HIV in 2015 were unaware of their infection. Among the 39,720 persons with HIV infection diagnosed in 2015, the estimated median diagnosis delay was 3.0 years (interquartile range = 0.7–7.8 years); diagnosis delay varied by race/ethnicity (from 2.2 years among whites to 4.2 years among Asians) and transmission category (from 2.0 years among females who inject drugs to 4.9 years among heterosexual males). Among persons interviewed through National HIV Behavioral Surveillance, 71% of men who have sex with men, 58% of persons who inject drugs, and 41% of heterosexual persons at increased risk for HIV infection reported testing in the past 12 months. In each risk group, at least two thirds of persons who did not have an HIV test had seen a health care provider in the past year.ConclusionsDelayed HIV diagnoses continue to be substantial for some population groups and prevent early entry to care to improve health outcomes and reduce HIV transmission to others.Implications for Public Health PracticeHealth care providers and others providing HIV testing can reduce HIV-related adverse health outcomes and risk for HIV transmission by implementing routine and targeted HIV testing to decrease diagnosis delays.

Purpose of the article: Globally, an estimated 4.2 million people above the age of 50 now have diagnosis of HIV (Human Immunodeficiency Virus) infection. Patients with HIV can now survive well into old age. Aging with HIV has been associated with medical illness however neuropsychiatric symptoms including cognitive decline and behavioral dysregulation has been directly associated with aging and having HIV. The article will talk about common neuropsychiatric diagnosis with HIV and discuss some interventions that may be used for successful aging with HIV. Findings: A detailed literature review using indexed peer reviewed literature using databases such as Medline, PubMed and Cochrane reviews show that untreated HIV illness over a long period of time can both cause both cognitive and behavioral changes as well as precipitate underlying existing illnesses. All providers are encouraged to begin treatment with Highly Active Antiretroviral Therapy (HAART). Early screening for both behavioral and cognitive disorders is encouraged and timely referrals to mental health professionals is of utmost importance. Conclusion: Persons with HIV now have increased longevity given newer and more innovative treatment with anti-retroviral treatment (ART). However, persons with HIV are at increased risk for both neurological and psychiatric illness. Early detection, assessment and treatment are key to ensure aging successfully. A collaborative multidisciplinary team comprising of individuals from infectious diseases, mental health, social work and nursing is essential for optimal neuropsychiatric health in older persons with HIV.

Human immunodeficiency virus (HIV) infection is associated with increased cardiovascular disease (CVD) events. Endothelial dysfunction (EDF) is involved in CVD pathogenesis; however, EDF onset after HIV acquisition and the potential for reversibility with antiretroviral therapy (ART) have not been evaluated to date. To evaluate endothelial function with noninvasive reactive hyperemia index (RHI) in patients with early HIV infection at baseline and after ART initiation. Cohort study in which 61 members of the United States Air Force diagnosed with HIV infection from September 1, 2015, through September 30, 2017, were evaluated for baseline EDF. Natural log-transformed RHI values (lnRHI) of less than 0.51 and at least 0.51 were defined as abnormal and normal, respectively. The RHI interval changes were evaluated in a subgroup of 40 patients. Data were analyzed from September 30, 2017, through January 30, 2018. Early HIV infection. Baseline EDF at HIV diagnosis and interval changes associated with ART initiation. The 61 patients included in the analysis were predominantly male (58 [95%]) and mostly African American (35 [57%]), with a mean (SD) age of 28.1 (6.7) years at HIV diagnosis. Median time from estimated date of HIV seroconversion to RHI assessment was 10.6 months (interquartile range [IQR], 5.1-13.2 months), and the median CD4 lymphocyte count was 552/μL (IQR, 449/μL-674/μL). Patients had a mean (SD) body mass index of 26.2 (4.0), median (IQR) low-density lipoprotein cholesterol level of 97 (80-126) mg/dL, median (IQR) total cholesterol level of 163 (146-195) mg/dL, and no diabetes diagnoses. Overall mean (SD) lnRHI was 0.70 (0.29) at HIV diagnosis. Baseline RHI was normal in 47 patients (77%; mean [SD] lnRHI, 0.82 [0.20]) and was abnormal in 14 patients (23%; mean [SD] lnRHI, 0.30 [0.18]). Age (per 10-year increase) was not associated with an abnormal lnRHI (odds ratio, 2.15; 95% CI, 0.89-5.19; P = .09). Of the 41 patients with follow-up RHI assessments, 40 started ART immediately and repeated the RHI assessments at a median (IQR) of 6.4 (6.0-7.8) months. Use of ART was associated with an overall significan increase in mean (SD) lnRHI (0.13 [0.33]; P = .02). A greater increase in mean (SD) lnRHI was associated with abnormal (n = 11) compared with normal (n = 29) lnRHI at HIV diagnosis (0.33 [0.34]; P = .01 vs 0.04 [0.30]; P = .38). Among those with abnormal baseline lnRHI, 8 (73%) showed improved endothelial function after ART. The patient who declined ART converted from having a normal lnRHI (0.60) to an abnormal lnRHI (0.11) lnRHI after 8.3 months. In this study, EDF was common in early HIV infection, with associated reversal in most patients taking ART. Results suggest that persistent EDF and CVD complications may be associated with delayed ART. Further studies are necessary to define the role of noninvasive endothelial function testing in patients with HIV infection.

Objective: To examine differences, at the census tract level, in the distribution of human immunodeficiency virus (HIV) diagnoses and social determinants of health (SDH) among women with diagnosed HIV in 2017 in the United States and Puerto Rico. Background: In the United States, HIV continues to disproportionately affect women, especially minority women and women in the South. Methods: Data reported in the National HIV Surveillance System (NHSS) of the Centers for Disease Control and Prevention were used to determine census tract-level HIV diagnosis rates and percentages among adult women (aged ≥18 years) in 2017. Data from the American Community Survey were combined with NHSS data to examine regional differences in federal poverty status, education level, income level, employment status, and health insurance coverage among adult women with diagnosed HIV infection in the United States and Puerto Rico. Results: In the United States and Puerto Rico, among 6,054 women who received an HIV diagnosis in 2017, the highest rates of HIV diagnoses generally were among those who lived in census tracts where the median household income was less than $40,000; at least 19% lived below the federal poverty level, at least 18% had less than a high school diploma, and at least 16% were without health insurance. Conclusion: This study is the first of its kind and gives insight into how subpopulations of women are affected differently by the likelihood of an HIV diagnosis. The findings show that rates of HIV diagnosis were highest among women who lived in census tracts having the lowest income and least health coverage.

Donor evaluation in the era of HIV-positive organ transplantation: The importance of the infectious diseases specialist.

Although highly active antiretroviral therapy (HAART) has been introduced over twenty years ago to treat Human Immunodeficiency Virus (HIV) positive patients, acquired immunodeficiency syndrome (AIDS) is still one of the deadliest diseases found worldwide. AIDS prevalence and mortality rates are usually more pronounced in resource-constrained countries than in the developed world. The lack of trained medical technicians, sophisticated diagnostic equipment, and the overall scarcity of medical infrastructures have severely impacted HIV/AIDS diagnostics, which hinders the initiation and periodic monitoring of antiretroviral therapy (ART). Currently, available HIV viral load assays are not well-suited for resource-limited settings due to their high cost and a requirement for medical/technical infrastructures. In this paper, we review current and emerging diagnostic assays for HIV detection, with a focus on point-of-care (POC) based immunoassays for viral load measurement, drug resistance, and HIV recurrence. We also discuss the limitations of the available HIV assays and highlight the technological advancements in cellphone, paper, and flexible material-based assays which have the potential to improve HIV diagnosis and monitoring, thus assisting with the management of the disease.

Introduction: This case report describes a serious complication of delayed human immunodeficiency virus (HIV) diagnosis in a patient initially misdiagnosed with palliative-stage cancer and subsequently diagnosed with B-cell lymphoma. This situation highlights the diagnostic challenges and treatment implications following HIV diagnosis, and underscores the critical importance of accurate and timely HIV detection in oncology patients.Case presentation: A 39-year-old man was initially diagnosed with lung cancer based on computed tomography and histopathologic findings. He was treated with 2 lines of chemotherapy over an 8-month period, the neoplastic lung lesions progressed, and he was referred to palliative care. Two years after his initial diagnosis, during the management of an actively bleeding gastric tumor, he was diagnosed with HIV and referred to an infectious disease unit. Immediate antiretroviral treatment was initiated after diagnosis, and further evaluation confirmed the presence of B-cell lymphoma. A retrospective review suggested that the initial cancer diagnosis was likely misinterpreted and was in fact lymphoma, a malignancy commonly associated with HIV. Lymphoma treatment was initiated, and after 1 year, the patient achieved HIV-1 virologic suppression and near-complete remission of all lesions.Conclusions: This case highlights the consequences of delayed HIV diagnosis, which can significantly alter treatment course and patient prognosis. The initial misdiagnosis of cancer and subsequent ineffective treatment highlights the importance of HIV testing, particularly in patients presenting with malignancy. It also highlights the role of multidisciplinary collaboration, the need for prompt initiation of antiretroviral therapy, and the efficacy of targeted anticancer therapies for HIV-associated malignancies.

Objectives:Sub-Saharan Africa is at the epicentre of the human immunodeficiency virus (HIV) epidemic and has the highest incidence of invasive cervical cancer (ICC) in the world. Access to highly active antiretroviral treatment (HAART) in South Africa is still limited and provided only to nonpregnant women with a CD4+ T-cell count <200 μg/L. We evaluated the relative distribution of cervical preinvasive and invasive neoplasia among HIV-infected (treated or not) and uninfected women in the Limpopo Province of South Africa.Methods:We compared the consecutive biopsy-diagnosed cervical pathology of 1,023 HIV-infected and 1,023 uninfected women. We investigated the influence of the CD4+ T-cell count and of HAART on the relative distribution of cervical pathology.Results:There was a significantly higher proportion of cervical intraepithelial neoplasia (CIN)1 (P = 0.012) and 2 (P = 0.01) but a lower proportion of ICC (P = 0.015) among HIV-infected women. Patients on HAART had less CIN1 (P = 0.018), 2 (P = 0.18) and ICC (P = 0.019) that their untreated counterparts. The mean CD4 count was similar regardless of cervical lesions and HAART or no treatment.Conclusion:Our data support the concept that HIV-infected women exhibit a higher rate of high-grade preinvasive lesions than uninfected controls. However, they have a significantly lower rate of ICC as compared with uninfected counterparts. The inclusion of ICC among acquired immune deficiency syndrome-defining illnesses is questionable.

Objectives Literature shows that sexual activity remains important at older age and is a valued part of life. However, little is known about the intimate partner relationships (IPR) among minority older women living with Human Immunodeficiency Virus (HIV). The purpose of this study is to explore the effect HIV diagnosis had on the intimate partner relationships (IPR) among minority older women living with HIV (MOWH). Methods Qualitative descriptive study. A total of 28 MOWH (Black and Latinas) aged 50 years and older participated in face to face semi-structured in-depth interviews. Interviews were analyzed using content analysis. Results Three themes emerged from the analysis: (a)“Intimate partner relationships before HIV diagnosis” that revealed sexual practices increasing the risk for HIV in their intimate relationships; (b)“Facing relationship consequences of HIV disclosure after diagnosis” explored the consequences of HIV disclosure, and how disclosure determined the future of their intimate relationships; and (c) “Intimate partner relationships after HIV diagnosis” described the quality of intimate partner relationships and changes after HIV diagnosis. Conclusions Results from this study contribute to understanding and increasing awareness of the effect of HIV on the intimacy of MOWH. Clinical Implications Education provided by health care workers and interventions targeting MOWH should address the effect of HIV in IPR, address MOWH’s concerns about it, and help them to improve their overall health.

Venous thrombotic events (VTEs) may occur at higher rates among patients with HIV; some studies suggest that highly active antiretroviral therapy (HAART) may increase the risk for these potentially life-threatening events. We performed a retrospective study among patients with HIV to evaluate the incidence and risk factors for VTEs during the HAART era. A literature review was performed examining VTEs in the pre- and post-HAART eras. Seventeen (3.7%) of 465 patients with HIV experienced a VTE. The overall incidence rate of deep VTEs among HIV-positive persons was 377 cases per 100,000 person-years, a fourfold higher rate compared to age-matched males in the general population. The median age at VTE was 36 years (range, 27-68). Patients with a thrombosis compared to those without had significantly lower current CD4 (153 versus 520 cells/mm(3), p < 0.001) and nadir (76 versus 276 cells/mm(3), p < 0.001) CD4 counts, higher viral loads (3.6 versus 1.7 log(10) copies per milliliter, p = 0.003), and more likely to have a diagnosis of AIDS (76% versus 32%, p < 0.001); there were no differences in demographics, hyperlipidemia, current use of HAART, the duration of HAART or protease inhibitor (PI) exposure. A review of the literature noted 129 VTE cases; mean age was 40 years, mean CD4 count was 181 cells/mm(3), the majority of patients were not receiving HAART, and the most common risk factor was an ongoing infection. Thrombotic events are occurring among patients with HIV despite their relatively young ages. Advanced HIV disease is a risk factor for development of thromboses, possibly due to an increased inflammatory state or the presence of concurrent comorbidities such as infections. HAART or PI therapy does not appear to play a significant role in the occurrence of VTEs.

Are HIV-infected patients candidates for liver transplantation?