CD4, Viral Load Response, and Adherence Among Antiretroviral-Naive Breast-feeding Women Receiving Triple Antiretroviral Prophylaxis for Prevention of Mother-to-Child Transmission of HIV in Kisumu, Kenya

BACKGROUND:: Health benefits and survival of an exclusively breast-fed infant is dependent on the mother's health; thus, the need for antiretroviral (ARV) intervention for prevention of mother-to-child transmission (PMTCT). Achieving maternal health benefits from these regimens requires adherence to the treatments and close monitoring. We evaluated virologic, immunologic responses, and adherence among women receiving maternal triple ARV prophylaxis consisting of lamivudine/zidovudine and nevirapine or nelfinavir in the Kisumu Breastfeeding Study. METHODS:: We analyzed baseline demographic data, trends in CD4 count, and viral load (VL) at enrollment (32-34 weeks gestation), delivery, 14 and 24 weeks postpartum among 434 women who remained in the study at 24 weeks postpartum. Adherence rates were determined using pill counts reinforced by self-report and drug calendar. We dichotomized adherence as ≥95% versus <95%. RESULTS:: Among the 434 women, 84% (n = 366) had adherence ≥95%. The proportion of women with undetectable VL (<400 copies/mL) increased from 6% at baseline to 79%, and that of those with CD4 count <250 cells per microliter decreased from 23% (100) at baseline to 5% (22) at 24 weeks postpartum. In discrete-survival model, time to achieving VL suppression was associated with baseline VL <5.0 log copies per milliliter, parity ≥2, and use of nelfinavir- versus nevirapine-based ARV. Association between undetectable VL with duration of therapy (P < 0.0001) and adherence with suppression of VL (P = 0.001) was observed. CONCLUSIONS:: High baseline VL and short exposure to ARVs for PMTCT are risk factors for failing to achieve undetectable VL. These findings support the new WHO guidelines for early initiation of ARV prophylaxis for PMTCT for maximal reduction of maternal VL.     

Performances on the CogState and standard neuropsychological batteries among HIV patients without dementia

HIV-associated neurocognitive disorders remain prevalent but challenging to diagnose particularly among non-demented individuals. To determine whether a brief computerized battery correlates with formal neurocognitive testing, we identified 46 HIV-infected persons who had undergone both formal neurocognitive testing and a brief computerized battery. Simple detection tests correlated best with formal neuropsychological testing. By multivariable regression model, 53% of the variance in the composite Global Deficit Score was accounted for by elements from the brief computerized tool (P < 0.01). These data confirm previous correlation data with the computerized battery. Using the five significant parameters from the regression model in a Receiver Operating Characteristic curve, 90% of persons were accurately classified as being cognitively impaired or not. The test battery requires additional evaluation, specifically for identifying persons with mild impairment, a state upon which interventions may be effective.     

HIV Prevalence Rates Among Men Who Have Sex with Men in the Southern United States: Population-Based Estimates by Race/Ethnicity

States across the U.S. lack effective ways to quantify HIV prevalence rates among men who have sex with men (MSM). We estimated population-based HIV prevalence rates among MSM in the 17 southern states by race/ethnicity. Through 2007, estimated HIV prevalence rates per 100,000 MSM ranged from 2,607.6 among white (non-Hispanic) MSM in Maryland to 41,512.9 among black (non-Hispanic) MSM in the District of Columbia. Black MSM rates significantly exceeded Hispanic and white MSM rates in each state. Significant racial/ethnic disparities in rates persisted in a sensitivity analysis examining the possibility that minority MSM populations had been underestimated in each state. Compared with black, Hispanic, and white non-MSM males, respectively, rates at the regional level were 25.2 times higher for black MSM, 43.0 times higher for Hispanic MSM, and 106.0 times higher for white MSM. State-level analysis of racial/ethnic-specific MSM HIV prevalence rates can help guide resource allocation and assist advocacy.     

Performance of the Aptima HIV-1 RNA Qualitative Assay with 16- and 32-Member Specimen Pools

The Aptima HIV-1 RNA qualitative assay tested with a WHO-approved HIV type 1 RNA standard in 16- and 32-member pools detected 100% of the pools (1,070 and 2,130 HIV-1 RNA copies/ml/pool, respectively), thus exceeding the FDA-required lower limit of detection. The Aptima test can be used to screen for acute-phase HIV infection.Since 1999, pooled nucleic acid amplification testing (NAAT) for HIV type 1 (HIV-1) and hepatitis C virus has been used by blood donor screening programs (1, 8, 11). In 2002, the North Carolina Department of Health and Human Services and the University of North Carolina at Chapel Hill evaluated the use of pooled NAAT to screen for acute-phase HIV infection among a routine testing population and concluded that pooling specimens for NAAT is feasible in public health practice (10). The Centers for Disease Control and Prevention (CDC) initiated the Acute HIV-1 Infection (AHI) study in 2006 to investigate the utility of pooled NAAT with third-generation antibody screening to identify acute-phase HIV infection cases in targeted and routine screening programs. The CDC AHI study chose the 16-member pooled HIV-1 NAAT so that test results could be reported within 7 days after specimen collection (9). As part of this study, we evaluated the sensitivity of the Aptima HIV-1 RNA qualitative assay in 16- and 32-member pools.The Aptima HIV-1 RNA qualitative assay (Gen-Probe Inc., San Diego, CA) was approved by the FDA in October 2006 as an aid in the diagnosis of HIV infection but not for HIV-1 detection in pooled specimens (4). Because no guidelines exist for using a pooled HIV-1 RNA protocol for routine HIV screening, we chose HIV RNA levels for our evaluation that were above and below the FDA blood donor sensitivity requirement of 5,000 copies/ml/specimen in minipools of blood product (5). The Aptima product insert (3) states that when a diluted WHO standard is used, the lowest detection limit is 33 copies/ml/specimen (100% reliability). For our study, the three HIV RNA testing standards were prepared at the CDC laboratory by diluting a WHO standard containing 150,000 HIV-1 RNA copies/ml in HIV-negative plasma to 1,070 (level 1), 2,130 (level 2), and 5,330 (level 3) copies/ml for final concentrations of 67, 133, and 333 copies/ml/16-member pool, respectively (7). These testing standards were requantified in triplicate in three separate runs by using the Roche Cobas Amplicor HIV-1 Monitor test, v1.5 (Roche Molecular Systems, Inc., Pleasanton, CA). Dilution-specific group means and standard deviations were calculated as the mean of means by using least-squares regression and assuming constant variance in all vials (6). Given the imprecision of viral load estimates at low concentrations, we rounded estimates to two significant digits. The HIV-1 RNA levels in the three CDC-prepared standards were 900, 2,500, and 6,100 copies/ml, representing 1:16-diluted concentrations of 56, 156, and 381 copies/ml/16-member pool, respectively (Table ​(Table1).1). Aliquots of each standard were put in coded vials, stored at −70°C, and shipped on dry ice to the New York State Department of Health (NYSDOH) laboratory.

TABLE 1.

Characterization of secondary HIV-1 RNA standards used to construct 16- and 32- member specimen pools

AIDS-defining opportunistic illnesses in the HAART era in New York City

Despite widespread availability of HAART, opportunistic illnesses (OIs) still occur and result in an increased risk of mortality among persons with AIDS. We estimated the incidence of OIs among all new adult AIDS cases in New York City in 2000 overall and in demographic and clinical subgroups and identified factors associated with occurrence of an AIDS-defining OI versus AIDS diagnosis based on low CD4+ values only. In 2000, 5,451 new AIDS cases were reported to the New York City Department of Health and Mental Hygiene. Of these 27.4% (95% CI: 22.8-32.6) had at least one OI, most frequent being Pneumocystis jiroveci pneumonia (12.2%) and M. tuberculosis (5.3%); 47.1% (41.7-52.5) had a late HIV diagnosis (i.e.< or =6 months before AIDS diagnosis). Persons with a late HIV diagnosis not in recent care had a 3.5-fold increased odds (1.29-9.63) of an OI, compared to non-late testers in care. Other predictors of an OI were injection drug use and older age. We conclude that OIs remain prevalent in the HAART era and late testers not in care are especially likely to develop an OI. Our results support comprehensive HIV programs promoting early HIV testing and linkage to care to prevent OI-related morbidity and mortality.     

Factors Associated With Condom Use Problems During Vaginal Sex With Main and Non-Main Partners

BACKGROUND:: Incorrect condom use is a common problem that can undermine their prevention impact. We assessed the prevalence of 2 condom use problems, breakage/slippage and partial use, compared problems by partnership type, and examined associations with respondent, partner, and partnership characteristics. METHODS:: Data were collected at 3-month intervals during a 12-month period (1999-2000) among urban sexually transmitted disease (STD) clinic users. Condom use problems were compared between partnership types using z tests for equality of proportions. Logistic generalized estimating equations modeling accounted for within-participant correlation of repeated measures. RESULTS:: Overall 3297 respondents reported 9304 main and 6793 non-main partnerships; condoms were used at least once in 4942 (53.0%) and 4523 (66.6%) of these partnerships, respectively. Condom breakage/slippage was reported during 6.0% of uses (5.1% main, 9.4% non-main) and partial use during 12.5% of uses (12.8% main, 11.5% non-main). The proportion of respondents experiencing any condom use problem in the prior 3 months was higher among main compared with non-main partnerships: 39.1% versus 29.9% had either problem; 22.5% versus 19.0% had breakage/slippage only; 21.8% versus 18.7% had partial use; and 8.7% versus 7.1% had both use problems. In multivariable analysis, factors associated with condom use problems varied by partnership type and respondent sex. The most common predictors of problems across models were sex while high and inconsistent condom use. CONCLUSIONS:: This study highlights the diverse set of risk factors for condom use problems at the individual, partner, and partnerships levels.