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1.  Elevated CD8 Counts During HAART are Associated with HIV Virologic Treatment Failure 
Objective
To evaluate whether elevated CD8 counts are associated with increased risk of virologic treatment failure in HIV-infected individuals.
Design
Retrospective cohort study.
Methods
U.S. Military HIV Natural History Study participants who initiated HAART in 1996-2008, had 6- and 12-month post-HAART HIV RNA <400 c/ml, ≥2 subsequent HIV viral loads and a baseline CD8 count were eligible (n=817). Baseline was 12 months after HAART start, virologic failure was defined as confirmed HIV RNA ≥400 c/ml, and CD8 counts ≥1200 cells/mm3 were considered elevated. Cox models were used to examine the effect of baseline and time-updated CD8 counts on virologic failure.
Results
There were 216 failures for a rate of 5.6 per 100 person-years (95% confidence interval [CI] 4.9-6.4). Among those initiating HAART in 2000-2008, participants with elevated baseline CD8 counts had significantly greater risk of virologic failure compared to those with baseline CD8 counts ≤600 cells/mm3 (hazard ratio [HR] = 2.68, 95% CI 1.13 – 6.35). Participants with elevated CD8 counts at >20% of prior 6-month follow-up visits had greater risk of failure at the current visit than those who did not (HR = 1.53, 95% CI 1.14 - 2.06). Those with CD8 counts that increased after HAART start had greater risk of failure than those with CD8 counts that decreased or remained the same (HR = 1.59, 95% CI 1.19 – 2.13).
Conclusions
Initial or serial elevated CD8 counts while on HAART or an increase in CD8 counts from HAART initiation may be early warnings for future treatment failure.
doi:10.1097/QAI.0b013e318221c62a
PMCID: PMC3173352  PMID: 21602694
Human immunodeficiency virus; CD8 count; antiretroviral therapy; HIV viral load suppression; HIV virologic failure
2.  Are Time- and Event-based Prospective Memory Comparably Affected in HIV Infection?† 
According to the multi-process theory of prospective memory (ProM), time-based tasks rely more heavily on strategic processes dependent on prefrontal systems than do event-based tasks. Given the prominent frontostriatal pathophysiology of HIV infection, one would expect HIV-infected individuals to demonstrate greater deficits in time-based versus event-based ProM. However, the two prior studies examining this question have produced variable results. We evaluated this hypothesis in 143 individuals with HIV infection and 43 demographically similar seronegative adults (HIV−) who completed the research version of the Memory for Intentions Screening Test, which yields parallel subscales of time- and event-based ProM. Results showed main effects of HIV serostatus and cue type, but no interaction between serostatus and cue. Planned pair-wise comparisons showed a significant effect of HIV on time-based ProM and a trend-level effect on event-based ProM that was driven primarily by the subset of participants with HIV-associated neurocognitive disorders. Nevertheless, time-based ProM was more strongly correlated with measures of executive functions, attention/working memory, and verbal fluency in HIV-infected persons. Although HIV-associated deficits in time- and event-based ProM appear to be of comparable severity, the cognitive architecture of time-based ProM may be more strongly influenced by strategic monitoring and retrieval processes.
doi:10.1093/arclin/acr020
PMCID: PMC3081684  PMID: 21459901
AIDS dementia complex; Episodic memory; Executive functions; Neuropsychological assessment
3.  A Randomized Clinical Trial Comparing Revaccination with Pneumococcal Conjugate Vaccine (PCV) to Polysaccharide Vaccine (PPV) among HIV-Infected Adults 
The Journal of infectious diseases  2010;202(7):1114-1125.
Background
The risk of pneumococcal disease persists and antibody responses to revaccination with the 23-valent polysaccharide vaccine (PPV) are low among HIV-infected adults. We determined whether revaccination with the 7-valent pneumococcal conjugate vaccine (PCV) would enhance these responses.
Methods
In a randomized clinical trial, we compared the immunogenicity of revaccination with PCV (n=131) or PPV (n=73) among HIV-infected adults (median CD4 count 533 cells/mm3) vaccinated with PPV 3–8 years earlier. HIV-uninfected adults (n=25) without prior pneumococcal vaccination received one dose of PCV. A positive response was defined as a ≥2-fold rise (baseline to day 60) in capsule-specific IgG with a post-vaccination level value ≥1000 ng/ml for at least 2 of the 4 serotypes.
Results
HIV-infected persons demonstrated a higher frequency of positive antibody responses to PCV vs. PPV (57% vs. 36%, p=0.004) and greater IgG concentration mean changes from baseline to day 60 for serotypes 4, 9V, and 19F (all p<0.05), but not for serotype 14. However by day 180 both outcomes were similar. Responses to PCV were greater in frequency and magnitude for all serotypes in HIV-uninfected compared with those in HIV-infected adults.
Conclusions
Among persons with HIV infection, revaccination with PCV was only transiently more immunogenic than PPV, and responses were inferior to those in HIV-uninfected subjects with primary vaccination. Pneumococcal vaccines with more robust and sustained immunogenicity are needed for HIV-infected adults.
doi:10.1086/656147
PMCID: PMC2932785  PMID: 20795819
4.  Clinical and Epidemiologic Characteristics of an Outbreak of Novel H1N1 (Swine Origin) Influenza A Virus among United States Military Beneficiaries 
Background
A novel swine-origin influenza A (H1N1) virus was identified in March 2009 and subsequently caused worldwide outbreaks. The San Diego region was an early focal point of the emerging pandemic. We describe the clinical and epidemiologic characteristics of this novel strain in a military population to assist in future outbreak prevention and control efforts.
Methods
We performed an epidemiologic evaluation of novel H1N1 virus infections diagnosed in San Diego County among 96,258 local US military beneficiaries. The structured military medical system afforded the ability to obtain precise epidemiologic information on the impact on H1N1 virus infection in a population. The novel H1N1 virus was confirmed using real-time reverse transcriptase polymerase chain reaction (rRT-PCR).
Results
From 21 April through 8 May 2009, 761 patients presented with influenza-like illness and underwent rRT-PCR testing. Of these patients, 97 had confirmed novel H1N1 virus infection, with an incidence rate of 101 cases per 100,000 persons. The median age of H1N1 patients with H1N1 virus infection was 21 years (interquartile range, 15–25 years). Fever was a universal symptom in patients with H1N1 virus infection; other symptoms included cough (present in 96% of patients), myalgia or arthralgia (57%), and sore throat (51%). Sixty-eight (70%) of our patients had an identifiable epidemiologic link to another confirmed patient. The largest cluster of cases of H1N1 virus infection occurred on a Navy ship and involved 32 (8%) of 402 crew members; the secondary attack rate was 6%–14%. The rapid influenza testing that was used during this outbreak had a sensitivity of 51% and specificity of 98%, compared with rRT-PCR. Only 1 patient was hospitalized, and there were no deaths.
Conclusions
A novel H1N1 influenza A virus caused a significant outbreak among military beneficiaries in San Diego County, including a significant cluster of cases onboard a Navy ship. The outbreak described here primarily affected adolescents and young adults and resulted in a febrile illness without sequelae.
doi:10.1086/648508
PMCID: PMC2878199  PMID: 19911946
5.  Melioidosis after Brief Exposure: A Serologic Survey in US Marines 
Melioidosis is endemic to Southeast Asia. The incidence of infection in visitors is not well known, especially for short visits. Thirteen (38%) of 34 previously unexposed U.S. Marines had positive serology after two weeks in Thailand, and one developed acute disseminated disease. Asymptomatic infection with Burkholderia pseudomallei may be common, even from brief exposures.
PMCID: PMC2774725  PMID: 19190209
Melioidosis; Burkholderia pseudomallei; military; Thailand; travel medicine
6.  Group A streptococcal toxic shock syndrome developing in the third trimester of pregnancy. 
BACKGROUND: Group A streptococcal (GAS) toxic shock syndrome (TSS) is an uncommon, but life-threatening infection during pregnancy and should be considered in rapid onset of shock. Most cases described in the literature have occurred in the puerperium. We report a case of GAS TSS occurring during the third trimester of pregnancy in a previously healthy woman. CASE: A 31-year-old female, who was 34 weeks pregnant, presented with fevers and a prodromal 'flu-like' illness. She rapidly developed shock and multiorgan failure. Blood cultures revealed GAS bacteremia and the patient met criteria for streptococcal TSS. Despite her eventual recovery, her infant died on postpartum day 15 as a consequence of the mother's TSS. CONCLUSIONS: This case is unusual in that there were no identifiable initiating events or source of the streptococcal infection, and the TSS developed during pregnancy rather than after delivery. Early recognition of GAS infections is important given the rapid onset and high morbidity and mortality associated with these infections. This is the first reported case utilizing intravenous immunoglobulin for GAS TSS in the puerperium.
PMCID: PMC1784620  PMID: 12648315
7.  Low prevalence of neurocognitive impairment in early diagnosed and managed HIV-infected persons 
Neurology  2013;80(4):371-379.
Objective:
To describe the prevalence of neurocognitive impairment (NCI) among early diagnosed and managed HIV-infected persons (HIV+) compared to HIV-negative controls.
Methods:
We performed a cross-sectional study among 200 HIV+ and 50 matched HIV-uninfected (HIV−) military beneficiaries. HIV+ patients were categorized as earlier (<6 years of HIV, no AIDS-defining conditions, and CD4 nadir >200 cells/mm3) or later stage patients (n = 100 in each group); both groups were diagnosed early and had access to care. NCI was diagnosed using a comprehensive battery of standardized neuropsychological tests.
Results:
HIV+ patients had a median age of 36 years, 91% were seroconverters (median window of 1.2 years), had a median duration of HIV of 5 years, had a CD4 nadir of 319, had current CD4 of 546 cells/mm3, and 64% were on highly active antiretroviral therapy (initiated 1.3 years after diagnosis at a median CD4 of 333 cells/mm3). NCI was diagnosed among 38 (19%, 95% confidence interval 14%–25%) HIV+ patients, with a similar prevalence of NCI among earlier and later stage patients (18% vs 20%, p = 0.72). The prevalence of NCI among HIV+ patients was similar to HIV− patients.
Conclusions:
HIV+ patients diagnosed and managed early during the course of HIV infection had a low prevalence of NCI, comparable to matched HIV-uninfected persons. Early recognition and management of HIV infection may be important in limiting neurocognitive impairment.
doi:10.1212/WNL.0b013e31827f0776
PMCID: PMC3589242  PMID: 23303852
8.  Cross-sectional assessment of prevalence and correlates of blood-borne and sexually-transmitted infections among Afghan National Army recruits 
BMC Infectious Diseases  2012;12:196.
Background
Few data are available in Afghanistan to shape national military force health practices, particularly with regard to sexually-transmitted infections (STIs). We measured prevalence and correlates of HIV, syphilis, herpes simplex 2 virus (HSV-2), and hepatitis C virus (HCV) among Afghan National Army (ANA) recruits.
Methods
A cross-sectional sample of male ANA recruits aged 18–35 years were randomly selected at the Kabul Military Training Center between February 2010 and January 2011. Participants completed an interviewer-administered questionnaire and serum-based rapid testing for syphilis and hepatitis C virus antibody on-site; HIV and HSV-2 screening, and confirmatory testing were performed off-site. Prevalence of each infection was calculated and logistic regression analysis performed to identify correlates.
Results
Of 5313 recruits approached, 4750 consented to participation. Participants had a mean age of 21.8 years (SD±3.8), 65.5% had lived outside Afghanistan, and 44.3% had no formal education. Few reported prior marijuana (16.3%), alcohol (5.3%), or opiate (3.4%) use. Of sexually active recruits (58.7%, N = 2786), 21.3% reported paying women for sex and 21.3% reported sex with males. Prevalence of HIV (0.063%, 95% CI: 0.013- 0.19), syphilis (0.65%, 95% CI: 0.44 – 0.93), and HCV (0.82%, 95% CI: 0.58 – 1.12) were quite low. Prevalence of HSV-2 was 3.03% (95% CI: 2.56 - 3.57), which was independently associated with age (Adjusted Odds Ratio (AOR) = 1.04, 95% CI: 1.00 - 1.09) and having a television (socioeconomic marker) (AOR = 1.46, 95% CI: 1.03 – 2.05).
Conclusion
Though prevalence of HIV, HCV, syphilis, and HSV-2 was low, sexual risk behaviors and intoxicant use were present among a substantial minority, indicating need for prevention programming. Formative work is needed to determine a culturally appropriate approach for prevention programming to reduce STI risk among Afghan National Army troops.
doi:10.1186/1471-2334-12-196
PMCID: PMC3482585  PMID: 22909128
Afghanistan; Military populations; HIV; Sexual risk behavior; Drug use

Results 1-8 (8)