Renal and metabolic toxicities following initiation of HIV-1 treatment regimen in a diverse, multinational setting: a focused safety analysis of ACTG PEARLS (A5175).

BACKGROUND: Convenient dosing, potency, and low toxicity support use of tenofovir disoproxil fumarate (TDF) as preferred nucleotide reverse transcriptase inhibitor (NRTI) for HIV-1 treatment. However, renal and metabolic safety of TDF compared to other NRTIs has not been well described in resource-limited settings. METHODS: This was a secondary analysis examining the occurrence of renal abnormalities (RAs) and renal and metabolic serious non-AIDS-defining events (SNADEs) through study follow-up between participants randomized to zidovudine (ZDV)/lamivudine/ efavirenz and TDF/emtricitabine/efavirenz treatment arms within A5175/PEARLS trial. Exact logistic regression explored associations between baseline covariates and RAs. Response profile longitudinal analysis compared creatinine clearance (CrCl) over time between NRTI groups. RESULTS: Twenty-one of 1,045 participants developed RAs through 192 weeks follow-up; there were 15 out of 21 in the TDF arm (P = .08). Age 41 years or older (odds ratio [OR], 3.35; 95% CI, 1.1-13.1), his- tory of diabetes (OR, 10.7; 95% CI, 2.1-55), and lower baseline CrCl (OR, 3.1 per 25 mL/min decline; 95% CI, 1.7-5.8) were associated with development of RAs. Renal SNADEs occurred in 42 participants; 33 were urinary tract infections and 4 were renal failure/insufficiency; one event was attributed to TDF. Significantly lower CrCl values were maintained among patients receiving TDF compared to ZDV (repeated measures analysis, P = .05), however worsening CrCl from baseline was not observed with TDF exposure over time. Metabolic SNADEs were rare, but were higher in the ZDV arm (20 vs 3; P < .001). CONCLUSIONS: TDF is associated with lower serious metabolic toxicities but not higher risk of RAs, serious renal events, or worsening CrCl over time compared to ZDV in this randomized multinational study.

Spectrum of malignancies among HIV-infected patients in South India.

INTRODUCTION: The current study examines the spectrum of malignancies among HIV-infected South Indians enrolled in a clinical care program. MATERIALS AND METHODS: We conducted a nested matched case-control study among 42 HIV-infected cases who developed cancer and 82 HIV-infected controls between 1998 and 2008 at a tertiary care HIV care program in South India. RESULTS: The most common types of cancer included non-Hodgkin's lymphoma (38.1%), Hodgkin's lymphoma (16.7%), squamous cell carcinoma (14.3%), and adenocarcinoma (14.3%). The median duration of time from HIV infection to cancer diagnosis was 549 days [interquartile range (IQR): 58-2013]. The nadir CD4 cell count was significantly lower in cases compared to controls (134 cells/µl vs. 169 cells/µl; P = 0.015). Cancer patients were more likely to have a more advanced HIV disease stage at the time of cancer diagnosis compared to control patients (Stage C: 90.5% vs. 49.4%; P<0.0001). Significantly more cancer patients were receiving antiretroviral treatment relative to control patients at the time of cancer diagnosis (92.9% vs. 66.3%; P=0.001). CONCLUSIONS: HIV-infected patients who developed cancer had more advanced immunodeficiency at the time of cancer diagnosis and a lower nadir CD4 cell count. It is possible that with the continued roll-out of highly active antiretroviral therapy in India, the incidence of HIV-associated malignancies will decrease.

Highly active antiretroviral therapy and employment status in accra, ghana.

OBJECTIVES: This study investigated the immunologic responses and employment history of highly-active antiretroviral therapy (HAART) patients. DESIGN: We interviewed patients and reviewed medical records to collect demographic, clinical, and employment history while on HAART. Demographic characteristics were tested as predictors of immunological response while on HAART using hierarchical linear models. SETTING: Fevers Unit, Korle-Bu Teaching Hospital, Accra, Ghana PARTICIPANTS: Subjects comprised a convenience sample of adult HAART patients receiving therapy for at least 9 months. 270 patients were interviewed. 38 were excluded due to inadequate time on HAART or inability to locate all necessary patient information. INTERVENTION: This was an observational study. MAIN OUTCOME MEASURES: We investigated the change in CD4 cell count and weight since the initiation of therapy, and their ability to maintain or regain employment as well as the reasons for this. RESULTS: The estimated mean ± standard error increase in CD4 cell count from baseline at 6, 12, and 18 months were 102 ± 5, 204 ± 11, and 236 ± 10 cells/µL, respectively. Overall, 147 patients (63.4%) reported remaining employed or obtaining new employment while on HAART. Patients who were asymptomatic at initial presentation were more likely to remain employed or returned to work while on HAART than those who were symptomatic (66.4% vs. 48.8%, P = 0.009). Most patients were employed in the informal sector, which made their economic situation particularly vulnerable to HIV-associated illness. CONCLUSION: The findings suggest that patients receiving HAART experience good clinical and immunological responses as well as improvement in employment status.

A randomised control trial of structured interrupted generic antiretroviral therapy versus continuous therapy in HIV-infected individuals in Southern India.

This randomised control trial, conducted in Chennai, India, compared structured interrupted therapy (SIT) and continuous therapy (CT) in relation to immunologic and virologic outcomes, adverse events (AEs) and cost of therapy. ART-naïve adult HIV1-infected participants with CD4 counts 50-350 cells/mm(3), and plasma viral load (PVL)>5000 copies/mL were enrolled and placed on Indian-manufactured generic ART: zidovudine(AZT)/stavudine(d4T)+lamivudine(3TC)+efavirenz(EFV). After at least six months of continuous therapy, subjects were randomised to SIT (one-week-on/one-week-off cycles) or CT. The primary end-point was the proportion of subjects maintaining CD4>200 cells/mm(3) at six and 12 months after randomisation. Secondary end-points were effective viral suppression (PVL<400 copies/mL), AEs and cost. All analyses used intention-to-treat methodology. Of 40 participants (69% male; mean age 36+/-7; median baseline CD4 and PVL: 162 cell/mm(3)and 259,000 copies/mL), 17 were randomised to SIT and 18 to CT. At randomisation, median CD4s for SIT and CT were 378 cells/mm(3) and 357 cells/mm(3), respectively. All participants had PVL<400 copies/mL at time of randomisation. Median CD4 six months after randomisation was 498 cells/mm(3) and 417 cells/mm(3) for SIT and CT respectively. All participants had CD4>200 cells/mm(3). One participant on CT and two on SIT had sustained PVL>400 copies/mL. There were no serious AEs or deaths. Structured interrupted therapy cost was half of CT. Structured interrupted therapy was effective at maintaining CD4 above 200 cells/mm(3). Adverse events were comparable in both groups, with 50% reduction in cost for SIT. Further research on such strategies may benefit resource-constrained settings.

HIV in couples in South India; implications for prevention.

We studied HIV prevalence in couples in Chennai, India. In 56% both partners were infected. Among discordant couples, 35 men and seven women were infected. Heterosexual intercourse is the primary risk factor. Concordance was related to sex with commercial sex workers for men and to genital ulcer disease for women. Median CD4 count was 97 cells/mm(3) among concordant men, 222 cells/mm(3) among discordant men. Condom use increased, and frequency of sexual intercourse decreased, among all couples after HIV diagnosis.

Highly active antiretroviral therapy (HAART) in adults with tuberculosis: current status.

The overlapping epidemiology of human immunodeficiency virus (HIV) infection and tuberculosis (TB) and the catastrophic consequences of the interactions between the two epidemics have led to increased morbidity and mortality due to HIV-associated TB. While effective therapy is available for both conditions, there are major challenges in the concurrent treatment of HIV and TB co-infection. This review examines the interactions between HIV and TB infections and reviews the current status of highly active antiretroviral therapy (HAART) in patients with co-infection. Specific questions relating to optimal timing of concurrent HAART, challenges to concurrent HAART, optimal regimens and future considerations are discussed.

Internet sex-seeking leads to acute HIV infection: a report of two cases.

The use of the internet provides a rapid medium for identifying potential sexual partners and arranging in-person meetings that often result in sex. There is growing concern that the internet facilitates the transmission of sexually transmitted diseases and HIV. We report the first two cases of acute HIV infection after internet chat room encounters. Physicians should address the potential risks to sex seekers who use the internet. HIV prevention efforts that target internet sex seekers are needed.

Discordant Human Immunodeficiency Virus Type 1 drug resistance mutations, including K103N, observed in cerebrospinal fluid and plasma.

Discordant resistance mutations were seen in human immunodeficiency virus type 1 (HIV-1) isolated from specimens of blood and cerebrospinal fluid (CSF) obtained from 3 of 6 patients. To our knowledge, this is the first report of HIV-1 isolated from CSF harboring the K103N mutation, which confers resistance to the nonnucleoside reverse-transcriptase inhibitors, and this finding may indicate that virus in the CSF replicates independently from virus in the blood compartment.

Highly active antiretroviral therapy decreases mortality and morbidity in patients with advanced HIV disease.

BACKGROUND: Mortality and morbidity related to AIDS have decreased among HIV-infected patients taking highly active anti-retroviral therapy (HAART), but previous studies may have been confounded by other changes in treatment. OBJECTIVE: To assess the benefit of HAART in patients with advanced AIDS and anemia. DESIGN: Prospective, multicenter cohort study. SETTING: The Viral Activation Transfusion Study (VATS), with enrollment from August 1995 through July 1998 and follow-up through June 1999. PATIENTS: 528 HIV-infected patients with cytomegalovirus (CMV) seropositivity or disease who were receiving a first red blood cell transfusion for anemia. MEASUREMENTS: In a person-year analysis of follow-up before and after initiation of HAART, Poisson regression was used to calculate crude rate ratios and rate ratios adjusted for CD4 count, HIV RNA level, calendar period, time on study, sex, ethnicity, and injection drug use. RESULTS: At baseline, patients had a median CD4(+) lymphocyte count of 0.015 x 10(9) cell/L, median plasma HIV RNA level of 4.8 log(10) copies/mL, and median hemoglobin concentration of 73 g/L. Use of HAART increased from 1% of active patients in January 1996 to 79% of active patients in January 1999. The crude death rate was 0.24 event/person-year among patients taking HAART and 0.88 event/person-year among those not taking HAART (rate ratio, 0.26; adjusted rate ratio, 0.38; P < 0.001 for both comparisons). Rates of non-CMV disease were 0.15 event/ person-year after HAART and 0.45 event/person-year before HAART (crude rate ratio, 0.34 [ P < 0.001]; adjusted rate ratio, 0.66 [ P < 0.05]). Rates of CMV disease were 0.10 event/person-year after HAART and 0.25 before HAART (crude rate ratio, 0.42 [ P < 0.01]; adjusted rate ratio, 1.01 [ P > 0.2]). Results were similar in patients with baseline CD4(+) lymphocyte counts less than 0.010 x 10(9) cells/L. CONCLUSIONS: The data support an independent reduction in mortality and opportunistic events attributable to HAART, even in patients with very advanced HIV disease. However, patients with CMV infection or disease may not have a reduction in new CMV events due to HAART.

Enhancing adherence to HAART: a pilot program of modified directly observed therapy.

Based on the model of directly observed therapy (DOT) for tuberculosis, we implemented an uncontrolled pilot program of modified DOT to increase adherence to HAART. Participants met every weekday with an outreach worker who observed them taking the morning dose of HAART. Thirty-seven patients with a history of poor adherence were enrolled and followed for a mean duration of 10 months. The program was feasible and well accepted by the participants. Self-reported adherence to nonobserved doses improved, and those who remained in the program for a year (n = 18) demonstrated a mean 1.53-log decrease from baseline in plasma HIV RNA level.

HIV testing among young adults and older adolescents in the setting of acute substance abuse treatment.

OBJECTIVES: To examine the feasibility and acceptance of HIV testing among youth in acute substance abuse treatment. METHODS: Youth, aged 18 to 25 years old, in state-funded inpatient detoxification completed a confidential demographic/risk behavior questionnaire, and were offered a choice of no testing, serum-based testing, or oral fluid (Orasure, Epitope, Inc., Beaverton, OR, U.S.A.) HIV testing. RESULTS: In all, 74% of 204 participants accepted HIV testing. In a multivariate model, female gender (odds ratio [OR], 0.32; 95% confidence interval [CI] 0.14-0.74) and having been recently tested (OR, 0.11; 95% CI, 0.05-0.26) were independently associated with refusing testing. Recent sexual activity (OR, 5.4; 95% CI, 1.5-20.4), recent use of methamphetamines (speed) or a combination of cocaine and heroin (speedball) (OR, 3.8; 95% CI, 1.6-9.0), and a recent perceived risk for HIV (OR, 4.6; 95% CI, 1.9-10.9) were independently associated with test acceptance. Thus, 150 of 150 (100%) chose the Orasure test. Overall, 64.6% (97 of 150) of those tested received their results, but among participants requiring a follow-up appointment to learn test results, only 9.2% (8 of 87) returned. CONCLUSIONS: HIV testing is feasible and acceptable in this population. All patients preferred Orasure testing to a serum enzyme-linked immunosorbent assay (ELISA). Most youth tested in detoxification will only learn their results if they are provided during treatment. Rapid HIV testing with same-day results could improve follow-up rates.

Leukocyte-reduced red blood cell transfusions in patients with anemia and human immunodeficiency virus infection: the Viral Activation Transfusion Study: a randomized controlled trial.

CONTEXT: Allogeneic blood transfusions have immunomodulatory effects and have been associated with activation of human immunodeficiency virus (HIV) and cytomegalovirus (CMV) in vitro and of HIV in small pilot studies. Retrospective studies suggest that transfusions adversely affect the clinical course of HIV. Data in selected non-HIV-infected patients requiring blood transfusion have suggested clinical benefit with leukocyte-reduced red blood cells (RBCs). OBJECTIVE: To compare the effects of leukoreduced and unmodified RBC transfusions on survival, complications of acquired immunodeficiency syndrome, and relevant laboratory markers in HIV-infected patients. DESIGN AND SETTING: Double-blind randomized controlled trial conducted in 11 US academic medical centers from July 1995 through June 1999, with a median follow-up of 12 months (24 months in survivors). PATIENTS: A total of 531 persons infected with HIV and CMV, aged 14 years or older, who required transfusions for anemia; 259 received leukoreduced transfusions and 262 received unmodified transfusions (10 did not receive the planned transfusion). MAIN OUTCOME MEASURES: Survival and change in plasma HIV RNA level 7 days after transfusion, compared by type of transfusion. RESULTS: At entry, the groups were similar in demographic, clinical, and relevant laboratory characteristics. A total of 3864 RBC units were transfused. Two hundred eighty-nine deaths occurred (151 with leukoreduced transfusion; 138 with unmodified transfusion); median survival was 13.0 and 20.5 months, respectively (relative hazard [RH], 1.20; 95% confidence interval [CI], 0.95-1.51; log-rank P =.12). Analyses adjusted for prognostic factors suggested possible worse survival with leukoreduction (RH, 1.35; 95% CI, 1.06-1.72). There was no difference in time to new opportunistic event/death or frequency of transfusion reactions. No changes in plasma HIV RNA level were seen in either group at days 7, 14, 21, or 28, even in patients not taking antiretroviral drugs. There were no differences in trends between groups in CMV DNA, CD4 cell counts, activated (CD38% or human leukocyte antigen-DR) CD8 cell counts, or plasma cytokine levels. CONCLUSIONS: We found no evidence of HIV, CMV, or cytokine activation following blood transfusion in patients with advanced HIV infection. Leukoreduction provided no clinical benefit in these patients. These data demonstrate the importance of conducting controlled studies of effects of leukoreduction in different patient populations, since smaller studies in other patient populations have suggested leukoreduction may be beneficial.

Determinants of antimicrobial prophylaxis use and treatment for wasting among patients with advanced human immunodeficiency virus disease in the United States, 1995-1998.

Despite US Public Health Service (USPHS) recommendations for antimicrobial prophylaxis for patients with advanced human immunodeficiency virus (HIV) disease, the proportion of patients who receive prophylaxis is not known. We measured the prevalence of antimicrobial prophylaxis use, and treatment for HIV wasting at baseline among 531 patients with advanced HIV disease enrolled in a multicenter randomized trial of red blood cell transfusion. Use of antimicrobial prophylaxis and treatment for wasting in the 30 days before enrollment was ascertained in patients eligible for primary prophylaxis, secondary prophylaxis, or both, according to USPHS guidelines. There was high utilization of primary and secondary Pneumocystis carinii pneumonia prophylaxis, variability in primary Mycobacterium avium complex prophylaxis by center, and low use of primary cytomegalovirus prophylaxis. Treatment of wasting was more common in white than nonwhite patients and in patients with HIV disease who lived in the region west of the Mississippi River of the United States versus those whose lived in the eastern region.

Laboratory testing for infection with the human immunodeficiency virus: established and novel approaches.

The enzyme-linked immunosorbent assay (ELISA) and the Western blot are the primary tests for the diagnosis and confirmation of human immunodeficiency virus (HIV) infection. The ELISA, an inexpensive screening test for antibodies to HIV-1, is both sensitive and specific. The HIV-1 Western blot is a reliable confirmatory test following a repeatedly reactive ELISA. False-positive HIV-1 results with this sequence of tests are extremely rare but can occur, and test results that are inconsistent with clinical or other laboratory information should be questioned, repeated, or supplemented. The US Food and Drug Administration has also approved rapid and more accessible testing methods. Oral mucosal transudate and urine testing are noninvasive testing methods; rapid and home sample collection kits offer easier access to testing.

Paromomycin: no more effective than placebo for treatment of cryptosporidiosis in patients with advanced human immunodeficiency virus infection. AIDS Clinical Trial Group.

To evaluate the efficacy of paromomycin for the treatment of symptomatic cryptosporidial enteritis in human immunodeficiency virus-infected adults, we conducted a prospective, randomized, double-blind, placebo-controlled trial before the widespread introduction of highly active antiretroviral therapy (HAART). Seven units under the auspices of the AIDS Clinical Trials Group enrolled 35 adults with CD4 cell counts of < or = 150/mm(3). Initially, 17 patients received paromomycin (500 mg 4 times daily) and 18 received matching placebo for 21 days. Then all patients received paromomycin (500 mg q.i.d.) for an additional 21 days. Clinical definitions of response were measured by an average number of bowel movements per day in association with concurrent need for antidiarrheal agents that was lower than that before study entry. There was no treatment response during the placebo-controlled phase of the study according to protocol-defined criteria (P=.88). Three paromomycin recipients (17.6%) versus 2 placebo recipients (14.3%) responded completely. Rates of combined partial and complete responses in the paromomycin arm (8 out of 17, 47.1%) and the placebo arm (5 out of 14, 35.7%) of the study were also similar (P=.72). The clinical course of cryptosporidiosis was quite variable. Paromomycin was not shown to be more effective than placebo for the treatment of symptomatic cryptosporidial enteritis. However, inadequate statistical power prevents definitive rejection of the usefulness of paromomycin as therapy for this infection.

Modified wick method using Weck-Cel sponges for collection of human rectal secretions and analysis of mucosal HIV antibody.

Weck-Cel sponges were examined for suitability as an absorbent material for nontraumatic collection of rectal secretions in humans. Sponges were tested in vitro and determined by quantitative enzyme-linked immunosorbent assay (ELISA) to be capable of releasing 100% of absorbed albumin and all immunoglobulin subtypes after treatment with detergent-supplemented buffer. Protein composition in rectal secretions collected from normal women with dry sponges (DS) or with sponges previously softened by moistening with saline (MS) was subsequently compared. DS secretions showed evidence of contamination with blood and interstitial fluid-derived albumin, immunoglobulin G (IgG), and monomeric IgA. MS secretions appeared to represent local mucosal secretions more accurately because they contained negligible blood, a greater percentage of secretory IgA within the total IgA, and both lower albumin/IgG ratios and more dramatic alterations in IgG subclass distribution compared with corresponding serum. Anti-HIV IgG, IgM, IgA, and antibodies with secretory component could be demonstrated by ELISA in rectal secretions collected with moist sponges from 8 of 8, 1 of 8, 5 of 8, and 3 of 8 HIV-infected women, respectively. The data show that Weck-Cel sponges, if premoistened, can be used to collect rectal fluids nontraumatically and to obtain quantitative information about concentrations of immunoglobulins and specific antibodies on rectal mucosal surfaces.

Quantification of HIV-1-specific T-cell responses at the mucosal cervicovaginal surface.

OBJECTIVE: To characterize HIV-1 specific cellular immune responses at mucosal surfaces using a rapid, sensitive enzyme-linked immuno-spot (ELISPOT) technique. DESIGN: Cervicovaginal mononuclear cells obtained from cytobrush and cervicovaginal lavage were assessed for production of interferon-gamma (IFN-gamma) in response to stimulation by HIV-1 antigens. HIV-1 specific responses were compared in a cross-sectional study of two HIV-1-positive patient groups: women not currently on antiretroviral therapy with peripheral CD4 cell counts > 250 x 10(6)/l (n = 12); and women on highly active antiretroviral therapy (HAART) (n = 9). METHODS: Mononuclear cells from peripheral blood or cervicovaginal specimens were assessed in an ELISPOT assay for responses to HIV-1 antigens expressed by recombinant vaccinia viruses. This assay detects primarily CD8 T cells and shows good correlation with MHC class I tetramer staining of cytotoxic T lymphocytes. RESULTS: HIV-1 specific IFN-gamma spot-forming cells were detected in cervicovaginal samples of one out of nine women (11%) on HAART and five out of 12 women (42%) not currently on HAART. In peripheral blood mononuclear cells, HIV-1 specific IFN-gamma spot-forming cells were significantly more numerous in women not currently on HAART than in women on HAART (P = 0.009). In most cases, antigens recognized by mucosal T cells were also recognized by PBMC; however, there were exceptions. CONCLUSIONS: HIV-1-specific antigen-reactive T cells may be detected in routine, noninvasive gynecological specimens. The results suggest that cervicovaginal HIV-1-specific T cells may be less numerous in individuals on HAART than in those not on HAART, as shown previously for HIV-1-specific cytotoxic T lymphocytes in the peripheral blood.

Plasma human immunodeficiency virus (HIV) type 1 RNA load in men and women with advanced HIV-1 disease.

Several studies of patients infected with human immunodeficiency virus (HIV) type 1 have suggested that women have lower plasma HIV-1 RNA levels than men, even when controlling for CD4 T cell levels. A cross-sectional analysis was performed in 494 patients (21% of whom were women) who enrolled in a prospective study of anemic HIV-1-infected patients requiring transfusion. The median CD4 T cell count and plasma HIV-1 RNA levels were 15 cells/microL and 4.83 log(10) copies/mL (67,350 copies/mL), respectively. In unadjusted analyses, women had slightly higher mean log HIV-1 RNA titers than men (0.19 log(10) higher copies/mL; 95% confidence interval, -0.05 to 0.44; P=.11). Adjustment for CD4 T cell count, race or ethnicity, injection drug use, and age yielded a smaller sex difference (0.13 log(10) copies/mL higher in women; P=.28). In this population of patients with very advanced HIV disease, there is no evidence that women have lower HIV-1 RNA levels than men.

Effect of highly active antiretroviral therapy on cervicovaginal HIV-1 RNA.

OBJECTIVES: To determine the frequency of cervicovaginal lavage and plasma HIV-1 RNA levels that are below detectable levels (< 400 copies/ml) among women on highly active antiretroviral therapy (HAART), non-HAART and on no therapy. To compare the effect of initiating HAART on the timing of HIV-1 RNA suppression in the blood plasma and genital tract among antiretroviral-naïve women. METHODS: Data were obtained from 205 HIV-infected women with paired plasma and cervicovaginal lavage viral load measurements. Seven antiretroviral-naïve women starting HAART had viral load measurements performed daily for one week, at 2 weeks and at 1 month after initiating therapy. Viral load quantification was carried out by nucleic acid sequence-based amplification assay. The lower limit of detection was 400 copies/ml. RESULTS: Plasma and cervicovaginal HIV-1 RNA was detectable in 71 and 26% of the women, respectively. Among women with plasma viral loads less than 400, 400-9999, and 10,000 copies/ml or over, genital tract HIV-1 RNA was detected in 3, 17 and 48%, respectively (P < 0.001). Fifty-one per cent of the women with CD4 cell counts of less than 200/mm3 had detectable cervicovaginal viral loads compared with 18% among women with CD4 cell counts of 200/mm3 or over (P < 0.001). Cervicovaginal HIV-1 RNA was less than 400 copies/ml in 85% of those on HAART, 69% of those on non-HAART and 69% of those on no therapy (P < 0.045). In seven antiretroviral-naïve women initiating HAART, cervicovaginal HIV-1 RNA decreased by 0.7-2.1 log10 within 1-14 days of starting therapy. CONCLUSION: The cervicovaginal HIV-1 RNA level was positively correlated with plasma HIV-1 RNA and negatively with the CD4 cell count. The use of HAART was significantly associated with below-detectable levels of HIV-1 RNA in both plasma and the genital tract. HIV-1 RNA suppression in the genital tract may occur rapidly after initiating therapy.

Comprehensive medical care among HIV-positive incarcerated women: the Rhode Island experience.

Our objective was to characterize the clinical presentation of human immunodeficiency virus (HIV) infection among incarcerated women in a program that provides HIV testing and primary care to all state prisoners in Rhode Island. A retrospective medical chart review on all HIV-seropositive women who were incarcerated between 1989 and 1994 and had at least two medical visits with an HIV medical care provider was used. At the Rhode Island Adult Correctional Institution (ACI), under mandatory testing laws between 1989 and 1994, 28% (172 of 623) of all women were identified with HIV infection. Of the 172 women who tested seropositive in prison, 110 were included in the study. Of the 110 women followed, 84% reported injection drug use (IDU) as their primary risk factor, and 30% reported both IDU and sex work. The median CD4 count was 596/mm3, with 60% having a CD4 count >500 cells/mm3. The most common medical conditions were vaginal candidiasis, oral candidiasis, and bronchitis. Antiretroviral therapy was well accepted and followed community standards. Continuity of medical care after release was facilitated by the same physician caring for the patient in the community setting, with 83% of women following up for HIV care after release. The medical conditions noted reflect that these women are early in the course of their HIV disease when they are initially diagnosed. This comprehensive program in Rhode Island's state prison plays a central role in the diagnosis of HIV-seropositive women and provides counseling, primary medical and gynecological care, and linkage to community resources after release.