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1.  The Impact of Prescribed Opioids on CD4 Cell Count Recovery among HIV-Infected Patients Newly Initiating Antiretroviral Therapy 
HIV medicine  2016;17(10):728-739.
Certain prescribed opioids have immunosuppressive properties, yet their impact on clinically relevant outcomes, including antiretroviral therapy (ART) response among HIV-infected patients, remains understudied.
Using the Veterans Aging Cohort Study data, we conducted a longitudinal analysis of 4,358 HIV-infected patients initiating ART between 2002 and 2010 and then followed them for 24 months. The primary independent variable was prescribed opioid duration, categorized using pharmacy data as none prescribed, short-term (<90 days), and long-term (≥90 days). Outcomes included CD4 cell count over time. Analyses adjusted for demographics, comorbid conditions, ART type and year of initiation, and overall disease severity (ascertained with the VACS index). Sensitivity analyses examined whether effects varied according to baseline CD4 cell count, achievement of viral load suppression, and opioid properties (i.e., dose and known immunosuppressive properties).
Compared to those with none, patients with short-term prescribed opioids had a similar increase in CD4 cell count (rise per year: 74 vs. 68 cells/mm3, p=0.11), as did those with long-term prescribed opioids (rise per year: 74 vs. 75 cells/mm3, p=0.98). In sensitivity analysis, compared to those with none, short-term prescribed opioid effects were statistically significant among those with baseline CD4 cell count ≥500 cells/mm3 (rise per year: 52 vs. 20 cells/mm3, p=0.04); findings were otherwise unchanged.
Despite immunosuppressive properties intrinsic to opioids, prescribed opioids appeared to have no effect on CD4 cell counts over 24 months among HIV-infected patients initiating antiretroviral therapy.
PMCID: PMC5053822  PMID: 27186715
HIV; analgesics; opioid; CD4 lymphocyte count; disease progression; antiretroviral therapy
2.  Active Surveillance to Quantify the Burden of Norovirus in a U.S. Veterans Affairs (VA) Patient Population, Houston, 2015–2016 
Open Forum Infectious Diseases  2017;4(Suppl 1):S317.
Norovirus is the leading cause of acute gastroenteritis (AGE) outbreaks in the United States; however, little data exist on the burden of endemic norovirus disease among adults. Robust estimates of the norovirus disease burden among US adults are needed to inform assessment of potential norovirus vaccines, which are currently in development.
We conducted active surveillance for AGE at the Michael E. DeBakey Veteran’s Affairs (VA) Medical Center, where approximately 104,000 unique patients were served in 2016. Cases were defined as veterans with symptoms of AGE (≥3 loose stools, ≥2 vomiting episodes, or ≥1 episodes of both loose stool and vomiting, within 24 hours) occurring in the previous 10 days, who presented to the emergency department or outpatient clinics (outpatients), or were admitted to the hospital (inpatients). Patients without AGE symptoms in the prior 14 days were enrolled as controls. Demographic data and illness characteristics were collected from enrolled subjects, and stool samples were collected and tested using the FilmArray gastrointestinal panel. Norovirus positives were confirmed by real-time RT-PCR and genotyped after sequencing of conventional PCR products.
From November 1, 2015–November 30, 2016, 130 inpatient and 85 outpatient AGE cases, along with 20 inpatient and 37 outpatient controls, were enrolled and provided a stool specimen. Among cases, 201 (93%) were male, and 94 (44%) were ≥65 years; median duration of illness was 3 days (range, 1–10 days). Norovirus was detected in 12 (9%) inpatient and 15 (18%) outpatient cases; norovirus was not detected in any controls. Incidence of norovirus-associated hospitalization was 15/100,000 population, and was similar in hospitalized cases aged <65 years (14/100,000) and ≥65 years (15/100,000). Of 22 norovirus positive specimens genotyped, 13 (59%) were GII.4 Sydney.
This robust, active surveillance platform employed screening and enrollment of patients in a VA population meeting a standardized AGE case definition, as well as asymptomatic controls. Data from this study highlight the burden of norovirus in adults and importance of a norovirus vaccine.
R. L. Atmar, Takeda Vaccines, Inc.: Research Support, Research support. B. Lopman, HHS/NIH/NIAID: Grant Investigator, Grant recipient. Bill & Melinda Gates Foundation: Grant Investigator, Grant recipient.
PMCID: PMC5632071
3.  Weight Gain and Incident Diabetes among HIV Infected-Veterans Initiating Antiretroviral Therapy Compared to Uninfected Individuals 
The health implications of weight gain after antiretroviral therapy (ART) for HIV infection are not well characterized and may differ from weight gain among uninfected individuals. We use data from the Veterans Aging Cohort Study (VACS) to determine whether weight gain after ART has a similar association with incident type-2 diabetes mellitus (DM) as weight gained among HIV-uninfected (uninfected) individuals.
We explored associations of weight gain and incident diabetes (A1c ≥ 6.5 %), in VACS, a national observational study of HIV infected (HIV+) individuals demographically matched 1:2 to uninfected controls. From 2000 to 2011, weight change was assessed in the year following ART initiation for HIV+ individuals and date of first available BMI for uninfected individuals. We estimated hazard ratios (HR) and 95% CI adjusted for baseline BMI using Cox regression.
HIV+ individuals had lower prevalence of DM at baseline (12%, HIV+, 23% uninfected) and lower incident diabetes (5% HIV+, 11% uninfected). The association of weight gain with risk of DM was linear for HIV+ and uninfected but the slope of the association was steeper for HIV+. For each 5 pounds of weight gained, HIV+ had 14% increased risk of DM (HR, 1.14; 95% CI, 1.10–1.17) and uninfected individuals had 8% increased risk (HR: 1.08; 95% CI, 1.07–1.10) (p<0.01 for interaction).
Weight gained in the first year after ART initiation is associated with greater risk of DM than that among uninfected individuals. HIV+ individuals initiating ART who are not underweight should avoid substantial weight gain.
PMCID: PMC5023454  PMID: 27171741
Diabetes; HIV; weight gain; obesity; Veterans; Inflammation
4.  Proceedings of the 14th annual conference of INEBRIA 
Holloway, Aisha S. | Ferguson, Jennifer | Landale, Sarah | Cariola, Laura | Newbury-Birch, Dorothy | Flynn, Amy | Knight, John R. | Sherritt, Lon | Harris, Sion K. | O’Donnell, Amy J. | Kaner, Eileen | Hanratty, Barbara | Loree, Amy M. | Yonkers, Kimberly A. | Ondersma, Steven J. | Gilstead-Hayden, Kate | Martino, Steve | Adam, Angeline | Schwartz, Robert P. | Wu, Li-Tzy | Subramaniam, Geetha | Sharma, Gaurav | McNeely, Jennifer | Berman, Anne H. | Kolaas, Karoline | Petersén, Elisabeth | Bendtsen, Preben | Hedman, Erik | Linderoth, Catharina | Müssener, Ulrika | Sinadinovic, Kristina | Spak, Fredrik | Gremyr, Ida | Thurang, Anna | Mitchell, Ann M. | Finnell, Deborah | Savage, Christine L. | Mahmoud, Khadejah F. | Riordan, Benjamin C. | Conner, Tamlin S. | Flett, Jayde A. M. | Scarf, Damian | McRee, Bonnie | Vendetti, Janice | Gallucci, Karen Steinberg | Robaina, Kate | Clark, Brendan J. | Jones, Jacqueline | Reed, Kathryne D. | Hodapp, Rachel M. | Douglas, Ivor | Burnham, Ellen L. | Aagaard, Laura | Cook, Paul F. | Harris, Brett R. | Yu, Jiang | Wolff, Margaret | Rogers, Meighan | Barbosa, Carolina | Wedehase, Brendan J. | Dunlap, Laura J. | Mitchell, Shannon G. | Dusek, Kristi A. | Gryczynski, Jan | Kirk, Arethusa S. | Oros, Marla T. | Hosler, Colleen | O’Grady, Kevin E. | Brown, Barry S. | Angus, Colin | Sherborne, Sidney | Gillespie, Duncan | Meier, Petra | Brennan, Alan | de Vargas, Divane | Soares, Janaina | Castelblanco, Donna | Doran, Kelly M. | Wittman, Ian | Shelley, Donna | Rotrosen, John | Gelberg, Lillian | Edelman, E. Jennifer | Maisto, Stephen A. | Hansen, Nathan B. | Cutter, Christopher J. | Deng, Yanhong | Dziura, James | Fiellin, Lynn E. | O’Connor, Patrick G. | Bedimo, Roger | Gibert, Cynthia | Marconi, Vincent C. | Rimland, David | Rodriguez-Barradas, Maria C. | Simberkoff, Michael S. | Justice, Amy C. | Bryant, Kendall J. | Fiellin, David A. | Giles, Emma L. | Coulton, Simon | Deluca, Paolo | Drummond, Colin | Howel, Denise | McColl, Elaine | McGovern, Ruth | Scott, Stephanie | Stamp, Elaine | Sumnall, Harry | Vale, Luke | Alabani, Viviana | Atkinson, Amanda | Boniface, Sadie | Frankham, Jo | Gilvarry, Eilish | Hendrie, Nadine | Howe, Nicola | McGeechan, Grant J. | Ramsey, Amy | Stanley, Grant | Clephane, Justine | Gardiner, David | Holmes, John | Martin, Neil | Shevills, Colin | Soutar, Melanie | Chi, Felicia W. | Weisner, Constance | Ross, Thekla B. | Mertens, Jennifer | Sterling, Stacy A. | Shorter, Gillian W. | Heather, Nick | Bray, Jeremy | Cohen, Hildie A. | McPherson, Tracy L. | Adam, Cyrille | López-Pelayo, Hugo | Gual, Antoni | Segura-Garcia, Lidia | Colom, Joan | Ornelas, India J. | Doyle, Suzanne | Donovan, Dennis | Duran, Bonnie | Torres, Vanessa | Gaume, Jacques | Grazioli, Véronique | Fortini, Cristiana | Paroz, Sophie | Bertholet, Nicolas | Daeppen, Jean-Bernard | Satterfield, Jason M. | Gregorich, Steven | Alvarado, Nicholas J. | Muñoz, Ricardo | Kulieva, Gozel | Vijayaraghavan, Maya | Adam, Angéline | Cunningham, John A. | Díaz, Estela | Palacio-Vieira, Jorge | Godinho, Alexandra | Kushir, Vladyslav | O’Brien, Kimberly H. M. | Aguinaldo, Laika D. | Sellers, Christina M. | Spirito, Anthony | Chang, Grace | Blake-Lamb, Tiffany | LaFave, Lea R. Ayers | Thies, Kathleen M. | Pepin, Amy L. | Sprangers, Kara E. | Bradley, Martha | Jorgensen, Shasta | Catano, Nico A. | Murray, Adelaide R. | Schachter, Deborah | Andersen, Ronald M. | Rey, Guillermina Natera | Vahidi, Mani | Rico, Melvin W. | Baumeister, Sebastian E. | Johansson, Magnus | Sinadinovic, Christina | Hermansson, Ulric | Andreasson, Sven | O’Grady, Megan A. | Kapoor, Sandeep | Akkari, Cherine | Bernal, Camila | Pappacena, Kristen | Morley, Jeanne | Auerbach, Mark | Neighbors, Charles J. | Kwon, Nancy | Conigliaro, Joseph | Morgenstern, Jon | Magill, Molly | Apodaca, Timothy R. | Borsari, Brian | Hoadley, Ariel | Scott Tonigan, J. | Moyers, Theresa | Fitzgerald, Niamh M. | Schölin, Lisa | Barticevic, Nicolas | Zuzulich, Soledad | Poblete, Fernando | Norambuena, Pablo | Sacco, Paul | Ting, Laura | Beaulieu, Michele | Wallace, Paul George | Andrews, Matthew | Daley, Kate | Shenker, Don | Gallagher, Louise | Watson, Rod | Weaver, Tim | Bruguera, Pol | Oliveras, Clara | Gavotti, Carolina | Barrio, Pablo | Braddick, Fleur | Miquel, Laia | Suárez, Montse | Bruguera, Carla | Brown, Richard L. | Capell, Julie Whelan | Paul Moberg, D. | Maslowsky, Julie | Saunders, Laura A. | McCormack, Ryan P. | Scheidell, Joy | Gonzalez, Mirelis | Bauroth, Sabrina | Liu, Weiwei | Lindsay, Dawn L. | Lincoln, Piper | Hagle, Holly | Wallhed Finn, Sara | Hammarberg, Anders | Andréasson, Sven | King, Sarah E. | Vargo, Rachael | Kameg, Brayden N. | Acquavita, Shauna P. | Van Loon, Ruth Anne | Smith, Rachel | Brehm, Bonnie J. | Diers, Tiffiny | Kim, Karissa | Barker, Andrea | Jones, Ashley L. | Skinner, Asheley C. | Hinman, Agatha | Svikis, Dace S. | Thacker, Casey L. | Resnicow, Ken | Beatty, Jessica R. | Janisse, James | Puder, Karoline | Bakshi, Ann-Sofie | Milward, Joanna M. | Kimergard, Andreas | Garnett, Claire V. | Crane, David | Brown, Jamie | West, Robert | Michie, Susan | Rosendahl, Ingvar | Andersson, Claes | Gajecki, Mikael | Blankers, Matthijs | Donoghue, Kim | Lynch, Ellen | Maconochie, Ian | Phillips, Ceri | Pockett, Rhys | Phillips, Tom | Patton, R. | Russell, Ian | Strang, John | Stewart, Maureen T. | Quinn, Amity E. | Brolin, Mary | Evans, Brooke | Horgan, Constance M. | Liu, Junqing | McCree, Fern | Kanovsky, Doug | Oberlander, Tyler | Zhang, Huan | Hamlin, Ben | Saunders, Robert | Barton, Mary B. | Scholle, Sarah H. | Santora, Patricia | Bhatt, Chirag | Ahmed, Kazi | Hodgkin, Dominic | Gao, Wenwu | Merrick, Elizabeth L. | Drebing, Charles E. | Larson, Mary Jo | Sharma, Monica | Petry, Nancy M. | Saitz, Richard | Weisner, Constance M. | Young-Wolff, Kelly C. | Lu, Wendy Y. | Blosnich, John R. | Lehavot, Keren | Glass, Joseph E. | Williams, Emily C. | Bensley, Kara M. | Chan, Gary | Dombrowski, Julie | Fortney, John | Rubinsky, Anna D. | Lapham, Gwen T. | Forray, Ariadna | Olmstead, Todd A. | Gilstad-Hayden, Kathryn | Kershaw, Trace | Dillon, Pamela | Weaver, Michael F. | Grekin, Emily R. | Ellis, Jennifer D. | McGoron, Lucy | McGoron, Lucy
PMCID: PMC5606215
5.  Hepatic safety of buprenorphine in HIV-infected and uninfected patients with opioid use disorder: The role of HCV-infection 
Individuals with HIV and hepatitis C (HCV) infection, alcohol use disorder, or who are prescribed potentially hepatotoxic medications may be at increased risk for buprenorphine (BUP) associated hepatotoxicity.
Materials and methods
We examined a cohort of HIV-infected and uninfected patients receiving an initial BUP prescription between 2003 and 2012. We compared changes in alanine and aspartate aminotransferases (ALT and AST) and total bilirubin (TB) stratified by HIV status. We identified cases of liver enzyme elevation (LEE), TB elevation (TBE), and conducted chart review to assess for cases of drug induced liver injury (DILI) and death. We examined associations between age, sex, race, HIV-infection, HCV-infection, alcohol use disorder, and prescription of other potentially heptatotoxic medications with the composite endpoint of LEE, TBE, and DILI.
Of 666 patients prescribed BUP, 36% were HIV-infected, 98% were male, 60% had RNA-confirmed HCV infection, 50% had a recent diagnosis of alcohol use disorder, and 64% were prescribed other potentially hepatotoxic medications. No clinically significant changes were observed in median ALT, AST and TB and these changes did not differ between HIV-infected and uninfected patients. Compared with uninfected patients, HIV-infected (OR 7.3, 95% CI 2.1-26.1, p=0.002), HCV-infected (OR 4.9 95% CI 1.6-15.2, p=0.007) or HIV/HCV co-infected patients (OR 6.9, 95%CI 2.1-22.2, p=0.001) were more likely to have the composite endpoint of LEE, TB elevation or DILI, in analyses that excluded 60 patients with evidence of pre-existing liver injury. 31 patients had LEE, 14/187 HIV-infected and 17/340 uninfected (p = 0.25); 11 had TBE, including 9/186 HIV-infected and 2/329 uninfected (p = 0.002); 8 experienced DILI, 4/202 HIV-infected and 2/404 uninfected (p = 0.45). There were no significant associations with alcohol use disorder or prescription of other potentially hepatotoxic medications after adjustment for HIV/HCV status.
Liver enzymes and TB are rarely elevated in HIV-infected and uninfected patients receiving BUP. Risk of hepatotoxicity was greater in individuals infected with HIV, HCV, or HIV/HCV co-infection, who may benefit from increased monitoring.
PMCID: PMC4976086  PMID: 27431048
buprenorphine; HIV; Hepatitis C; drug induced liver injury
6.  Fracture prediction with modified-FRAX in older HIV-infected and uninfected men 
FRAX® is a validated, computer-based clinical fracture risk calculator that estimates 10-year risk of major osteoporotic (clinical spine, forearm, hip or shoulder) fracture, and hip fracture alone. It is widely used for decision-making in fracture prevention, but may underestimate risk in HIV-infected individuals. Some experts recommend considering HIV a cause of secondary osteoporosis when calculating FRAX in HIV-infected individuals.
From the Veterans Aging Study Virtual Cohort (VACS-VC), we included 24451 HIV-infected and uninfected 50-70 year old men with complete data in year 2000 to approximate all but two factors (i.e. history of secondary osteoporosis and parental hip fracture) for modified-FRAX calculation without bone density and 10-year observational data for incident fragility fracture. Accuracy of the modified-FRAX calculation was compared by observed/estimated (O/E) ratios of fracture by HIV status.
Accuracy of modified-FRAX was less for HIV-infected (O/E=1.62, 95%CI: 1.45, 1.81) than uninfected men (O/E=1.29, 95%CI: 1.19, 1.40), but improved when HIV was included as a cause of secondary osteoporosis (O/E=1.20, 95%CI: 1.08, 1.34). However, only 3-6% of men with incident fractures were correctly identified by the modified-FRAX using accepted FRAX thresholds for pharmacologic therapy.
Modified-FRAX underestimated fracture rates more in older HIV-infected than otherwise similar uninfected men. Accuracy improved when HIV was included as a cause of secondary osteoporosis, but it still performed poorly for case-finding. Further studies are necessary to determine how to use FRAX or define an HIV-specific index to risk stratify for screening and treatment in older HIV-infected individuals.
PMCID: PMC4942335  PMID: 27003493
fracture incidence; HIV; men; FRAX
7.  Time trends in cancer incidence in persons living with HIV/AIDS in the antiretroviral therapy era: 1997–2012 
AIDS (London, England)  2016;30(11):1795-1806.
Utilizing the Veterans Aging Cohort Study, the largest HIV cohort in North America, we conducted one of the few comprehensive comparisons of cancer incidence time trends in HIV-infected (HIV+) versus uninfected persons during the antiretroviral therapy (ART) era.
Prospective cohort study.
We followed 44,787 HIV+ and 96,852 demographically-matched uninfected persons during 1997–2012. We calculated age-, sex-, and race/ethnicity-standardized incidence rates (IR) and incidence rate ratios (IRR, HIV+ versus uninfected) over four calendar periods with IR and IRR period trend p-values for cancer groupings and specific cancer types.
We observed 3,714 incident cancer diagnoses in HIV+ and 5,760 in uninfected persons. The HIV+ all cancer crude IR increased between 1997–2000 and 2009–2012 (p-trend=0.0019). However, after standardization, we observed highly significant HIV+ IR declines for all cancer (25% decline; p-trend<0.0001), AIDS-defining cancers (ADC; 55% decline; p-trend<0.0001), non-AIDS-defining cancers (NADC; 15% decline; p-trend=0.0003), and non-virus-related NADC (20% decline; p-trend<0.0001); significant IRR declines for all cancer (from 2.0 to 1.6; p-trend<0.0001), ADC (from 19 to 5.5; p-trend<0.0001), and non-virus-related NADC (from 1.4 to 1.2; p-trend=0.049); and borderline significant IRR declines for NADC (from 1.6 to 1.4; p-trend=0.078) and virus-related NADC (from 4.9 to 3.5; p-trend=0.071).
Improved HIV care resulting in improved immune function most likely contributed to the HIV+ IR and the IRR declines. Further promotion of early and sustained ART, improved ART regimens, reduction of traditional cancer risk factor (e.g., smoking) prevalence, and evidence-based screening could contribute to future cancer incidence declines among HIV+ persons.
PMCID: PMC4925286  PMID: 27064994
acquired immunodeficiency syndrome; HIV infections; neoplasms; cancer; Veterans
8.  Do Biomarkers Of Inflammation, Monocyte Activation And Altered Coagulation Explain Excess Mortality Between HIV Infected and Uninfected People? 
HIV infection and biomarkers of inflammation (measured by interleukin-6 [IL-6]), monocyte activation (soluble CD14 [sCD14]), and coagulation (D-dimer) are associated with morbidity and mortality. We hypothesized that these immunologic processes mediate (explain) some of the excess risk of mortality among HIV infected (HIV+) versus uninfected people independently of co-morbid diseases.
Among 2350 (1521 HIV+) participants from the Veterans Aging Cohort Study Biomarker Cohort (VACS BC) we investigated whether the association between HIV and mortality was altered by adjustment for IL-6, sCD14 and D-dimer, accounting for confounders. Participants were followed from date of blood draw for biomarker assays (baseline) until death or 7/25/2013. Analyses included ordered logistic regression and Cox Proportional Hazards regression.
During 6·9 years (median), 414 deaths occurred. The proportional odds of being in a higher quartile of IL-6, sCD14 or D-dimer was 2-3 fold higher for viremic HIV+ versus uninfected people. Mortality rates were higher among HIV+ compared to uninfected people (incidence rate ratio (95% CI): 1·31 (1·06-1·62). Mortality risk increased with increasing quartiles of IL-6, sCD14 and D-dimer regardless of HIV status. Adjustment for IL-6, sCD14 and D-dimer partially attenuated mortality risk among HIV+ people with unsuppressed viremia (HIV-1 RNA≥10000 copies/mL) compared to uninfected people – hazard ratio (95% CI) decreased from 2·18 (1·60-2·99) to 2·00 (1·45-2·76).
HIV infection is associated with elevated IL-6, sCD14 and D-dimer, which are in turn associated with mortality. Baseline measures of these biomarkers partially mediate excess mortality risk among HIV+ versus uninfected people.
PMCID: PMC4867134  PMID: 26885807
HIV; mortality; inflammation; monocyte activation; coagulation
9.  Isolated Hepatitis B Core Antibody is Associated with Advanced Hepatic Fibrosis in HIV/HCV Infection but not in HIV infection alone 
HIV+/HCV+ persons with isolated HBcAb have a higher prevalence of advanced fibrosis than persons who are non-immune to HBV, who have resolved HBV, or who are HbsAb+ only.
PMCID: PMC4837046  PMID: 26829660
Hepatitis B Core Antibody; HIV; hepatitis C
10.  Quantitative and Qualitative Antibody Responses to Immunization With the Pneumococcal Polysaccharide Vaccine in HIV-Infected Patients After Initiation of Antiretroviral Treatment: Results From a Randomized Clinical Trial 
The Journal of Infectious Diseases  2014;211(11):1703-1711.
Background. Pneumococcal vaccination is recommended for human immunodeficiency virus-infected (HIV+) persons; the best timing for immunization with respect to initiation of antiretroviral therapy (ART) is unknown.
Methods. Double-blind, placebo-controlled trial in HIV+ with CD4+ T cells/µL (CD4) ≥ 200 randomized to receive the 23-valent pneumococcal polysaccharide vaccine (PPV23) or placebo at enrollment, followed by placebo or PPV23, respectively, 9–12 months later (after ≥6 months of ART). Capsular polysaccharide-specific immunoglobin (Ig) G and IgM levels to serotypes 1, 3, 4, 6B, and 23F, and opsonophagocytic killing activity (OPA) to serotypes 6B and 23F were evaluated 1 month postvaccination.
Results. One hundred seven subjects were enrolled, 72 (67.3%) were evaluable (36/group). Both groups had significant increases in pre- to 1-month postvaccination IgG levels, but negligible to IgM, and significant increases in OPA titers to serotype 6B but not to 23F. There were no significant differences between groups in serotype-specific IgM or IgG levels or OPA titers. For the combined groups, there was a significant correlation between serotype-specific IgG and OPA titers to 23F but not to 6B. There was no correlation between CD4, viral load and IgG responses.
Conclusions. In HIV+ with CD4 ≥ 200, delaying PPV23 until ≥6 months of ART does not improve responses and may lead to missed opportunities for immunization.
PMCID: PMC4471434  PMID: 25538270
antibody; HIV; pneumococcal vaccine; pneumococcal capsular polysaccharides; antiretroviral treatment
11.  HIV status and the risk of ischemic stroke among men 
Neurology  2015;84(19):1933-1940.
Given conflicting data regarding the association of HIV infection and ischemic stroke risk, we sought to determine whether HIV infection conferred an increased ischemic stroke risk among male veterans.
The Veterans Aging Cohort Study–Virtual Cohort consists of HIV-infected and uninfected veterans in care matched (1:2) for age, sex, race/ethnicity, and clinical site. We analyzed data on 76,835 male participants in the Veterans Aging Cohort Study–Virtual Cohort who were free of baseline cardiovascular disease. We assessed demographics, ischemic stroke risk factors, comorbid diseases, substance use, HIV biomarkers, and incidence of ischemic stroke from October 1, 2003, to December 31, 2009.
During a median follow-up period of 5.9 (interquartile range 3.5–6.6) years, there were 910 stroke events (37.4% HIV-infected). Ischemic stroke rates per 1,000 person-years were higher for HIV-infected (2.79, 95% confidence interval 2.51–3.10) than for uninfected veterans (2.24 [2.06–2.43]) (incidence rate ratio 1.25 [1.09–1.43]; p < 0.01). After adjusting for demographics, ischemic stroke risk factors, comorbid diseases, and substance use, the risk of ischemic stroke was higher among male veterans with HIV infection compared with uninfected veterans (hazard ratio 1.17 [1.01–1.36]; p = 0.04).
HIV infection is associated with an increased ischemic stroke risk among HIV-infected compared with demographically and behaviorally similar uninfected male veterans.
PMCID: PMC4433456  PMID: 25862803
12.  Cost-effectiveness of Collaborative Care for Depression in Human Immunodeficiency Virus Clinics 
To examine the cost-effectiveness of the HITIDES intervention.
Randomized controlled effectiveness and implementation trial comparing depression collaborative care with enhanced usual care.
Three Veterans Health Administration (VHA) HIV clinics in the Southern US.
249 HIV-infected patients completed the baseline interview; 123 were randomized to the intervention and 126 to usual care.
HITIDES consisted of an off-site HIV depression care team that delivered up to 12 months of collaborative care. The intervention used a stepped-care model for depression treatment and specific recommendations were based on the Texas Medication Algorithm Project and the VA/Department of Defense Depression Treatment Guidelines.
Main outcome measure(s)
Quality-adjusted life years (QALYs) were calculated using the 12-Item Short Form Health Survey, the Quality of Well Being Scale, and by converting depression-free days to QALYs. The base case analysis used outpatient, pharmacy, patient, and intervention costs. Cost-effectiveness was calculated using incremental cost effectiveness ratios (ICERs) and net health benefit (NHB). ICER distributions were generated using nonparametric bootstrap with replacement sampling.
The HITIDES intervention was more effective and cost-saving compared to usual care in 78% of bootstrapped samples. The intervention NHB was positive and therefore deemed cost-effective using an ICER threshold of $50,000/QALY.
In HIV clinic settings this intervention was more effective and cost-saving compared to usual care. Implementation of off-site depression collaborative care programs in specialty care settings may be a strategy that not only improves outcomes for patients, but also maximizes the efficient use of limited healthcare resources.
PMCID: PMC4626259  PMID: 26102447
13.  Association of COPD with risk for pulmonary infections requiring hospitalization in HIV-infected Veterans 
Pulmonary infections remain more common in HIV-infected (HIV+) compared to uninfected individuals. The increase in chronic lung diseases among aging HIV+ individuals may contribute to this persistent risk. We sought to determine whether chronic obstructive pulmonary disease (COPD) is an independent risk factor for different pulmonary infections requiring hospitalization among HIV+ patients.
We analyzed data from 41,993 HIV+ Veterans in the nationwide Veterans Aging Cohort Study Virtual Cohort (VACS-VC) from 1996–2009. Using ICD-9 codes, we identified baseline comorbid conditions, including COPD, and incident community-acquired pneumonia (CAP), pulmonary tuberculosis (TB) and Pneumocystis jirovecii pneumonia (PCP) requiring hospitalization within two years after baseline. We used multivariable Poisson regression to determine incidence rate ratios (IRR) associated with COPD for each type of pulmonary infection, adjusting for comorbidities, CD4+ cell count, HIV viral load, smoking status, substance use, vaccinations and calendar year at baseline.
Unadjusted incidence rates of CAP, TB and PCP requiring hospitalization were significantly higher among persons with COPD compared to those without COPD (CAP: 53.9 vs. 19.4 per 1,000 person-years; TB: 8.7 vs. 2.8; PCP: 15.5 vs. 9.2; p ≤0.001). In multivariable Poisson regression models, COPD was independently associated with increased risk of CAP, TB and PCP (IRR 1.94, 95% CI 1.64–2.30; IRR 2.60, 95% CI 1.70–3.97; and IRR 1.48, 95% CI 1.10–2.01, respectively).
COPD is an independent risk factor for CAP, TB and PCP requiring hospitalization among HIV+ individuals. As the HIV+ population ages, the growing burden of COPD may confer substantial risk for pulmonary infections.
PMCID: PMC4607625  PMID: 26181820
COPD; pulmonary infection; pneumonia; HIV; comorbidities
14.  Depression and HIV Infection are Risk Factors for Incident Heart Failure Among Veterans: Veterans Aging Cohort Study 
Circulation  2015;132(17):1630-1638.
Both HIV and depression are associated with increased heart failure (HF) risk. Depression, a common comorbidity, may further increase the risk of HF among HIV+ adults. We assessed the association between HIV, depression and incident HF.
Methods and Results
Veterans Aging Cohort Study (VACS) participants free from cardiovascular disease at baseline (N = 81,427; 26,908 HIV+, 54,519 HIV-) were categorized into four groups: HIV- without major depressive disorder (MDD) [reference]; HIV- with MDD; HIV+ without MDD; and HIV+ with MDD. ICD-9 codes from medical records were used to determine MDD and the primary outcome, HF. After 5.8 follow-up years, HF rates per 1000 person-years were highest among HIV+ participants with MDD (9.32; 95% CI, 8.20–10.6). In Cox proportional hazards models, HIV+ participants with MDD had significantly higher risk of HF [adjusted hazard ratio (aHR) = 1.68; 95% CI, 1.45–1.95] compared to HIV- participants without MDD. MDD was associated with HF in separate fully adjusted models for HIV- and HIV+ participants (aHR = 1.21; 1.06–1.37 and 1.29; 1.11–1.51, respectively). Among those with MDD, baseline antidepressant use was associated with lower risk of incident HF events (aHR = 0.76; 0.58–0.99).
Our study is the first to suggest MDD is an independent risk factor for HF in HIV+ adults. These results reinforce the importance of identifying and managing MDD among HIV+ patients. Future studies must clarify mechanisms linking HIV, MDD, antidepressants, and HF; and identify interventions to reduce HF morbidity and mortality in those with both HIV and MDD.
PMCID: PMC4624488  PMID: 26358261
HIV infection; depression; psychiatric comorbidity; heart failure; epidemiology
15.  Thirty-Day Postoperative Mortality Among Individuals With HIV Infection Receiving Antiretroviral Therapy and Procedure-Matched, Uninfected Comparators 
JAMA surgery  2015;150(4):343-351.
Antiretroviral therapy (ART) has converted human immunodeficiency virus (HIV) infection into a chronic condition, and patients now undergo a variety of surgical procedures, but current surgical outcomes are inadequately characterized.
To compare 30-day postoperative mortality in patients with HIV infection receiving ART with the rates in uninfected individuals.
Retrospective analysis of nationwide electronic medical record data from the US Veterans Health Administration Healthcare System, October 1, 1996, to September 30, 2010. Common inpatient surgical procedures were grouped using the Healthcare Cost and Utilization Project Clinical Classification System to match HIV-infected and uninfected patients in a 1:2 ratio. Data on 1641 patients with HIV infection receiving combination ART who were undergoing inpatient surgery were compared with data on 3282 procedure-matched, uninfected comparators. Poisson regression models of 30-day postoperative mortality were adjusted for procedure year, age, Charlson Comorbidity Index score, hemoglobin level, albumin level, HIV infection, CD4 cell count, and HIV-1 RNA level.
All-cause 30-day postoperative mortality.
The most common procedures in both groups were cholecystectomy (10.5%), hip arthroplasty (10.5%), spine surgery (9.8%), herniorrhaphy (7.4%), and coronary artery bypass grafting (7.0%). In patients with HIV infection, CD4 cell distributions were 80.0% with 200/µL or more, 16.3% with 50/µL to 199/µL, and 3.7% with less than 50/µL; 74.1% of patients with HIV infection had undetectable HIV-1 RNA. Human immunodeficiency virus infection was associated with higher 30-day postoperative mortality compared with the mortality in uninfected patients (3.4% [56 patients]) vs 1.6% [53]); incidence rate ratio [IRR], 2.11; 95% CI, 1.41–3.17; P < .001). CD4 cell count was inversely associated with mortality, but HIV-1 RNA provided no additional information. After adjustment, patients with HIV infection had increased mortality compared with uninfected patients at all CD4 cell count strata (≥500/µL: IRR, 1.92; 95% CI, 1.02–3.60; P = .04; 200–499/µL: IRR, 1.89; 95% CI, 1.20–2.98; P = .01; 50–199/µL: IRR, 2.66; 95% CI, 1.29–5.47; P = .01; and <50/µL: IRR, 6.21; 95% CI, 3.55–10.85; P < .001). Hypoalbuminemia (IRR, 4.35; 95% CI, 2.78–6.81; P < .001) and age in decades (IRR, 1.47; 95% CI, 1.23–1.76; P < .001) were also strongly associated with mortality.
Current postoperative mortality rates among individuals with HIV infection who are receiving ART are low and are influenced as much by hypoalbuminemia and age as by CD4 cell status. Human immunodeficiency virus infection and CD4 cell count are only 2 of many factors associated with surgical outcomes that should be incorporated into surgical decision making.
PMCID: PMC5015449  PMID: 25714794
16.  Adherence and HIV RNA Suppression in the Current Era of Highly Active Antiretroviral Therapy (HAART) 
We examined trends in adherence to highly active antiretroviral therapy (HAART) and HIV RNA suppression, and estimated the minimum cutoff of adherence to newer HAART formulations needed for HIV RNA suppression by regimen type.
We used VA pharmacy dispensing data from the Veterans Aging Cohort Study Virtual Cohort between October 2000 and September 2010, and defined adherence as the duration of time the patient had the medications available, relative to the total number of days between refills for all antiretrovirals in a year. Temporal trends in adherence and viral load suppression were examined by the patient's most frequently used HAART regimen in the year. The minimum needed adherence was defined as the level at which the odds of suppression was not significantly different than that observed with ≥95% adherence using repeated measures logistic regression.
21,865 HAART users contributed 82,217 person-years of follow-up. There was a significant increase (ptrend<0.001) in the proportion virally suppressed even among those with <95% adherence (2001: 38% to 2010: 84%) and the trend was similar when restricting to their first HAART regimen. For NNRTI multi-pill users, the odds of suppression did not differ for 85-89% adherence compared to those with ≥95% adherence, odds ratios: 0.82 (0.64,1.04), but for PI users, the odds of suppression significantly differed if adherence levels were <95% compared to ≥95% adherence.
Although all HIV-infected persons should be instructed to achieve perfect adherence, concerns of slightly lower adherence should not hinder prescribing new HAART regimens early in HIV infection.
PMCID: PMC4482798  PMID: 25886923
Adherence; current HAART; HIV RNA suppression; Veterans Health Administration Center
17.  Impact of Defined Clinical Population and Missing Data on Temporal Trends in HIV Viral Load Estimation within a Healthcare System 
HIV medicine  2015;16(6):346-354.
Community viral load (CVL) estimates vary based on analytic methods. We extended the CVL concept and used data from the Veterans Affairs Healthcare System (VA) to determine trends in the healthcare system viral load (HSVL), sensitivity to varying definitions of the clinical population, and assumptions regarding missing data.
We included HIV-infected patients in the Veterans Aging Cohort Study, 2000-2010, with >1 documented CD4 count, HIV-1 RNA or antiretroviral prescription (N=37,318). We created 6-month intervals including patients with ≥1 visit in the past 2 years. We assessed temporal trends in clinical population size, patient clinical status and mean HSVL and explored the impact of varying definitions of the clinical population and assumptions about missing viral load.
The clinical population size varied by definition, increasing from 16,000–19,000 patients in 2000 to 23,000–26,000 in 2010. The proportion of patients with suppressed HIV-1 RNA increased over time. Over 20% of patients had no viral load measured in a given interval or prior two years. Among patients with a current HIV-1 RNA, mean HSVL decreased from 97,800 in 2000 to 2,000 copies/mL in 2010. When current HIV-1 RNA data were unavailable and the HSVL was recalculated using the last available HIV-1 RNA, HSVL decreased from 322,300 to 9,900 copies/mL. HSVL was underestimated when using only current data in each interval.
The CVL concept can be applied to a healthcare system, providing a measure of healthcare quality. Like CVL, HSVL estimates depend on definitions of the clinical population and assumptions about missing data.
PMCID: PMC4478104  PMID: 25688937
HIV; community viral load; population surveillance; quality of health care; epidemiologic methods
18.  Weight Change After Antiretroviral Therapy and Mortality 
This study examines weight change in human immunodeficiency virus-infected veterans after 1 year of antiretroviral therapy (ART). Survival benefits of weight gain after ART initiation depended on baseline body mass index, and markers of disease severity predicted weight gain.
Background. Weight gain after antiretroviral therapy (ART) initiation is common, but its implication for mortality is unknown. We evaluated weight change in the first year after ART initiation and its association with subsequent mortality.
Methods. Human immunodeficiency virus-infected patients from the Veterans Aging Cohort Study (VACS) who initiated ART between 2000 and 2008, with weight recorded at baseline and 1 year later, were followed another 5 years for mortality. Baseline body mass index (BMI) was classified as underweight (<18.5 kg/m2), normal (18.5–24.9 kg/m2), overweight (25–29.9 kg/m2), and obese (≥30 kg/m2). We used multivariable Cox models to assess mortality risk with adjustment for disease severity using the VACS Index.
Results. The sample consisted of 4184 men and 127 women with a mean age of 47.9 ± 10.0 years. After 1 year of ART, median weight change was 5.9 pounds (2.7 kg) (interquartile range, −2.9 to 17.0 pounds, −1.3 to 7.7 kg). Weight gain after ART initiation was associated with lower mortality among underweight and normal-weight patients. A minimum threshold of 10- to 19.9-pound (4.5 to 9.0 kg) weight gain was beneficial for normal-weight patients (hazard ratio, 0.56; 95% confidence interval, .41–.78), but there was no clear benefit to weight gain for overweight/obese patients. Baseline weight, CD4 cell count status, and hemoglobin level were strongly associated with weight gain. Risk for weight gain was higher among those with greater disease severity, regardless of weight at initiation.
Conclusions. The survival benefits of weight gain after ART initiation are dependent on starting BMI. Weight gain after ART is associated with lower mortality for those who are not initially overweight.
PMCID: PMC4542664  PMID: 25761868
HIV; veterans; weight; antiretroviral therapy; BMI
19.  Do Biomarkers of Inflammation, Monocyte Activation, and Altered Coagulation Explain Excess Mortality Between HIV Infected and Uninfected People? 
Supplemental Digital Content is Available in the Text.
HIV infection and biomarkers of inflammation [measured by interleukin-6 (IL-6)], monocyte activation [soluble CD14 (sCD14)], and coagulation (D-dimer) are associated with morbidity and mortality. We hypothesized that these immunologic processes mediate (explain) some of the excess risk of mortality among HIV infected (HIV+) versus uninfected people independently of comorbid diseases.
Among 2350 (1521 HIV+) participants from the Veterans Aging Cohort Study Biomarker Cohort (VACS BC), we investigated whether the association between HIV and mortality was altered by adjustment for IL-6, sCD14, and D-dimer, accounting for confounders. Participants were followed from date of blood draw for biomarker assays (baseline) until death or July 25, 2013. Analyses included ordered logistic regression and Cox Proportional Hazards regression.
During 6.9 years (median), 414 deaths occurred. The proportional odds of being in a higher quartile of IL-6, sCD14, or D-dimer were 2–3 fold higher for viremic HIV+ versus uninfected people. Mortality rates were higher among HIV+ compared with uninfected people [incidence rate ratio (95% CI): 1.31 (1.06 to 1.62)]. Mortality risk increased with increasing quartiles of IL-6, sCD14, and D-dimer regardless of HIV status. Adjustment for IL-6, sCD14, and D-dimer partially attenuated mortality risk among HIV+ people with unsuppressed viremia (HIV-1 RNA ≥10,000 copies per milliliter) compared with uninfected people—hazard ratio (95% CI) decreased from 2.18 (1.60 to 2.99) to 2.00 (1.45 to 2.76).
HIV infection is associated with elevated IL-6, sCD14, and D-dimer, which are in turn associated with mortality. Baseline measures of these biomarkers partially mediate excess mortality risk among HIV+ versus uninfected people.
PMCID: PMC4867134  PMID: 26885807
HIV; mortality; inflammation; monocyte activation; coagulation
20.  Health outcomes among HIV-positive Latinos initiating antiretroviral therapy in North America versus Central and South America 
Latinos living with HIV in the Americas share a common ethnic and cultural heritage. In North America, Latinos have a relatively high rate of new HIV infections but lower rates of engagement at all stages of the care continuum, whereas in Latin America antiretroviral therapy (ART) services continue to expand to meet treatment needs. In this analysis, we compare HIV treatment outcomes between Latinos receiving ART in North America versus Latin America.
HIV-positive adults initiating ART at Caribbean, Central and South America Network for HIV (CCASAnet) sites were compared to Latino patients (based on country of origin or ethnic identity) starting treatment at North American AIDS Cohort Collaboration on Research and Design (NA-ACCORD) sites in the United States and Canada between 2000 and 2011. Cox proportional hazards models compared mortality, treatment interruption, antiretroviral regimen change, virologic failure and loss to follow-up between cohorts.
The study included 8400 CCASAnet and 2786 NA-ACCORD patients initiating ART. CCASAnet patients were younger (median 35 vs. 37 years), more likely to be female (27% vs. 20%) and had lower nadir CD4 count (median 148 vs. 195 cells/µL, p<0.001 for all). In multivariable analyses, CCASAnet patients had a higher risk of mortality after ART initiation (adjusted hazard ratio (AHR) 1.61; 95% confidence interval (CI): 1.32 to 1.96), particularly during the first year, but a lower hazard of treatment interruption (AHR: 0.46; 95% CI: 0.42 to 0.50), change to second-line ART (AHR: 0.56; 95% CI: 0.51 to 0.62) and virologic failure (AHR: 0.52; 95% CI: 0.48 to 0.57).
HIV-positive Latinos initiating ART in Latin America have greater continuity of treatment but are at higher risk of death than Latinos in North America. Factors underlying these differences, such as HIV testing, linkage and access to care, warrant further investigation.
PMCID: PMC4800379  PMID: 26996992
HIV; antiretroviral therapy; highly active; mortality; Latin America; North America; cohort studies
22.  Comparison of Risk and Age at Diagnosis of Myocardial Infarction, End-Stage Renal Disease, and Non-AIDS-Defining Cancer in HIV-Infected Versus Uninfected Adults 
Although HIV-infected veterans had a higher risk of myocardial infarction, end-stage renal disease, and non-AIDS-defining cancer, diagnosis with these conditions were occurring at similar ages compared with HIV-uninfected veterans.
Background. Although it has been shown that human immunodeficiency virus (HIV)-infected adults are at greater risk for aging-associated events, it remains unclear as to whether these events happen at similar, or younger ages, in HIV-infected compared with uninfected adults. The objective of this study was to compare the median age at, and risk of, incident diagnosis of 3 age-associated diseases in HIV-infected and demographically similar uninfected adults.
Methods. The study was nested in the clinical prospective Veterans Aging Cohort Study of HIV-infected and demographically matched uninfected veterans, from 1 April 2003 to 31 December 2010. The outcomes were validated diagnoses of myocardial infarction (MI), end-stage renal disease (ESRD), and non-AIDS-defining cancer (NADC). Differences in mean age at, and risk of, diagnosis by HIV status were estimated using multivariate linear regression models and Cox proportional hazards models, respectively.
Results. A total of 98 687 (31% HIV-infected and 69% uninfected) adults contributed >450 000 person-years and 689 MI, 1135 ESRD, and 4179 NADC incident diagnoses. Mean age at MI (adjusted mean difference, −0.11; 95% confidence interval [CI], −.59 to .37 years) and NADC (adjusted mean difference, −0.10 [95% CI, −.30 to .10] years) did not differ by HIV status. HIV-infected adults were diagnosed with ESRD at an average age of 5.5 months younger than uninfected adults (adjusted mean difference, −0.46 [95% CI, −.86 to −.07] years). HIV-infected adults had a greater risk of all 3 outcomes compared with uninfected adults after accounting for important confounders.
Conclusions. HIV-infected adults had a higher risk of these age-associated events, but they occurred at similar ages than those without HIV.
PMCID: PMC4318916  PMID: 25362204
HIV infection; aging; myocardial infarction; end-stage renal disease; non-AIDS-defining cancers
23.  Prevalence and correlates of obstructive sleep apnea among patients with and without HIV infection 
HIV medicine  2014;16(2):105-113.
In HIV-uninfected populations, obstructive sleep apnea (OSA) is commonly associated with cardiovascular disease, metabolic syndrome, and cognitive impairment. These comorbidities are common in HIV-infected patients, but there are scarce data regarding OSA in HIV-infected patients. Therefore, we examined the prevalence and correlates of OSA in a cohort of HIV-infected and uninfected patients.
Observational cohort study.
Electronic medical record and self-report data were examined in patients enrolled in the Veterans Aging Cohort Study (VACS) between 2002-2008 and followed through 2010. The primary outcome was OSA diagnosis, determined using ICD-9 codes, in HIV-infected compared with uninfected. We used regression analyses to determine the association between OSA diagnosis, symptoms and comorbidities in adjusted models.
Of 3,683 HIV-infected and 3,641 uninfected patients, 143 (3.9%) and 453 (12.4%) had a diagnosis of OSA (p<0.0001), respectively. HIV-infected patients were more likely to report symptoms associated with sleep and OSA such as tiredness and fatigue. Compared with uninfected patients with OSA, HIV-infected patients with OSA were younger, had lower BMIs, and were less likely to have hypertension. In models adjusting for these traditional OSA risk factors, HIV infection was associated with markedly reduced odds of OSA diagnosis (odds ratio=0.48; 95% confidence interval 0.39—0.60).
HIV-infected patients are less likely to receive a diagnosis of OSA. Future studies are needed to determine whether the lower prevalence of OSA diagnoses in HIV-infected patients is due to decreased screening and detection or due to a truly decreased likelihood of OSA in the setting of HIV.
PMCID: PMC4300288  PMID: 25230851
HIV; Sleep apnea obstructive; Sleep apnea syndromes; Fatigue; Obesity
24.  Human immunodeficiency virus infection, cardiovascular risk factor profile and risk for acute myocardial infarction 
Traditional cardiovascular disease risk factors (CVDRFs) increase the risk of acute myocardial infarction (AMI) among HIV infected (HIV+) patients. We assessed the association between HIV and incident AMI within CVDRF strata.
81322 participants (33% HIV+) without prevalent CVD from the Veterans Aging Cohort Study-Virtual Cohort (prospective study of HIV+ and matched HIV− veterans). Veterans were followed from first clinical encounter on/after 4/1/2003 until AMI/death/last follow-up date (12/31/2009).
HIV, CVDRFs (total cholesterol, cholesterol-lowering agents, blood-pressure (BP), BP medication, smoking, diabetes) used to create 6 mutually exclusive profiles: all CVDRFs optimal, 1+ non-optimal CVDRFs, 1+ elevated CVDRFs, and 1, 2, 3+ major CVDRFs.
Incident AMI (defined using enzyme, EKG clinical data, 410 inpatient ICD-9 (Medicare), and/or death certificates). Statistics: Cox models adjusted for demographics, comorbidity, and substance use.
858 AMIs (42% HIV+) occurred over 5.9 years (median). Prevalence of optimal cardiac health was <2%. Optimal CVDRF profile was associated with the lowest adjusted AMI rates. Compared to HIV− veterans, AMI rates among HIV+ veterans with similar CVDRF profiles were higher. Compared to HIV− veterans without major CVDRFs, HIV+ veterans without major CVDRFs had a 2-fold increased risk of AMI (HR: 2.0 95%CI: 1.0–3.9, p=0.044).
The prevalence of optimal cardiac health is low in this cohort. Among those without major CVDRFs, HIV+ veterans have twice the AMI risk. Compared to HIV− veterans with high CVDRF burden, AMI rates were still higher in HIV+ veterans. Preventing/reducing CVDRF burden may reduce excess AMI risk among HIV+ people.
PMCID: PMC4441201  PMID: 25588033
HIV; optimal cardiovascular health; myocardial infarction
25.  Veterans’ Perspectives on Interventions to Improve Retention in HIV Care 
PLoS ONE  2016;11(2):e0148163.
Poor retention in HIV medical care is associated with increased mortality among patients with HIV/AIDS. Developing new interventions to improve retention in HIV primary care is needed. The Department of Veteran Affairs (VA) is the largest single provider of HIV care in the US. We sought to understand what veterans would want in an intervention to improve retention in VA HIV care. We conducted 18 one-on-one interviews and 15 outpatient focus groups with 46 patients living with HIV infection from the Michael E. DeBakey VAMC (MEDVAMC). Analysis identified three focus areas for improving retention in care: developing an HIV friendly clinic environment, providing mental health and substance use treatment concurrent with HIV care and encouraging peer support from other Veterans with HIV.
PMCID: PMC4734714  PMID: 26829641

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