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OBJECTIVE: It is unclear how often anxiety is diagnosed and treated and whether anxiety treatment is associated with improved viral suppression in persons with HIV. In this study, we characterized the anxiety care continuum and its association with viral suppression in a large urban HIV clinic in the United States. DESIGN: Observational cohort study. METHODS: We described the anxiety care continuum by combining data on self-reported anxiety symptoms, engagement in mental health care, clinical diagnoses and prescriptions from 1,967 persons receiving HIV care and treatment in Baltimore, Maryland, from 2014-23. We examined cross-sectional associations with viral suppression. All analyses were stratified by sex and race/ethnicity; a secondary analysis adjusted for age, years in care, and depressive symptoms. RESULTS: Nearly 1 in 5 patients reported mild-severe symptoms of anxiety but were not currently receiving mental health care or pharmacologic treatment for anxiety; 6% of patients reported anxiety symptoms but were receiving treatment, and 7% had been treated for anxiety that was currently in remission. The prevalence of viral suppression ranged from 87-89% across the anxiety care continuum except among patients with untreated moderate-severe anxiety, only 81% of whom were virally suppressed (95% CI: 80, 83). In adjusted models, untreated moderate-severe anxiety remained associated with viral non-suppression across demographic groups. CONCLUSION: We observed a robust association between untreated anxiety and viral non-suppression in a large urban cohort of persons with HIV. Screening for anxiety may identify patients with unmet mental health care needs who face barriers to maintaining viral suppression.
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BACKGROUND: Since July 23, 2022, global mpox cases reached 92,546, with over 31,000 in the United States. Asymptomatic carriage is a critical mechanism influencing the global dissemination of mpox. Seroprevalence studies are crucial for determining the epidemic's true burden, but uncertainties persist in serologic assay performance and how smallpox vaccination may influence assay interpretation. OBJECTIVES: Our study aimed to assess the performance of several diagnostic assays among mpox-positive, vaccinated, and pre-outbreak negative control samples. This investigation sought to enhance our understanding and management of future mpox outbreaks. STUDY DESIGN: Serum samples from 10 mpox-positive, five vaccinated uninfected, and 137 pre-outbreak controls were obtained for serological testing. The mpox-positive samples were obtained around 100 days post symptom onset, and vaccinated patients were sampled approximately 90 days post-vaccination. Multiple diagnostic assays were employed, including four commercial ELISAs (Abbexa, RayBioTech, FineTest, ProteoGenix) and a multiplex assay (MesoScale Diagnostics (MSD)) measuring five mpox and five smallpox antigens. RESULTS: Three commercial ELISA kits had low specificity (<50â¯%). The Proteogenix ELISA targeting the E8L antigen had a 94â¯% sensitivity and 87â¯% specificity. The E8L antigen on the MSD assay exhibited the greatest distinction between exposure groups, with 98â¯% sensitivity and 93â¯% specificity. CONCLUSIONS: None of the assays could distinguish between mpox-positive and vaccinated samples. The MSD assay targeting the MPXV E8L antigen demonstrated the greatest differentiation between mpox-positive and pre-outbreak negative samples. Our findings underscore the imperative to identify sensitive and specific assays to monitor population-level mpox exposure and infection.
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OBJECTIVE: Integrase strand transfer inhibitors (INSTI) are associated with weight gain in people with HIV (PWH), but their impact on diabetes is unclear. We evaluated the association between switching from nonnucleoside reverse-transcriptase inhibitors (NNRTI) or protease inhibitors (PI) to INSTI and incident diabetes. DESIGN: Longitudinal cohort study. METHODS: We included PWH aged ≥18âyears from the Johns Hopkins HIV Clinical Cohort (2007-2023) without history of diabetes who had used NNRTI or PI for ≥180âdays. We followed participants up to 10âyears from HIV primary care visits where they switched to INSTI or continued NNRTI or PI. We estimated the hazard of incident diabetes associated with switching to INSTI using weighted Cox regression with robust variance estimator. RESULTS: We included 2075 PWH who attended 22 116 visits where they continued NNRTI or PI and 631 visits where they switched to INSTI. Switching to INSTI was associated with a weighted hazard ratio (wHR) of 1.11 [95% confidence interval (CI), 0.77-1.59] for incident diabetes. The association if no weight gain occurred during the first two years was not qualitatively different (wHR 1.22; 95% CI, 0.82-1.80). In a posthoc analysis, switching to INSTI conferred a significant wHR of 1.79 (95% CI, 1.13-2.84) for diabetes within the first two years but not after. CONCLUSIONS: Switching from NNRTI or PI to INSTI did not significantly increase overall diabetes incidence in PWH, although there may be elevated risk in the first two years. These findings can inform considerations when switching to INSTI-based regimens.
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Diabetes Mellitus , Infecções por HIV , Inibidores de Integrase de HIV , Humanos , Masculino , Infecções por HIV/tratamento farmacológico , Infecções por HIV/complicações , Feminino , Adulto , Pessoa de Meia-Idade , Estudos Longitudinais , Diabetes Mellitus/epidemiologia , Inibidores de Integrase de HIV/uso terapêutico , Inibidores de Integrase de HIV/efeitos adversos , Incidência , Substituição de Medicamentos/estatística & dados numéricos , Aumento de Peso , Inibidores da Transcriptase Reversa/efeitos adversos , Inibidores da Transcriptase Reversa/uso terapêuticoRESUMO
Orthopoxvirus-specific T-cell responses were analyzed in 10 patients who had recovered from Mpox including 7 people with human immunodeficiency virus (PWH). Eight participants had detectable virus-specific T-cell responses, including a PWH who was not on antiretroviral therapy and a PWH on immunosuppressive therapy. These 2 participants had robust polyfunctional CD4+ T-cell responses to peptides from the 121L vaccinia virus (VACV) protein. T-cells from 4 of 5 HLA-A2-positive participants targeted at least 1 previously described HLA-A2-restricted VACV epitope, including an epitope targeted in 2 participants. These results advance our understanding of immunity in convalescent Mpox patients.
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Mpox , Orthopoxvirus , Humanos , Antígeno HLA-A2 , Vaccinia virus , Epitopos , Proteínas ViraisRESUMO
A 72-year-old man presented to the emergency department with fevers, night sweats, and rash 3 days after condomless vaginal intercourse. Results of a fourth-generation HIV test were positive and HIV-1-/2 antibody differentiation testing was negative. How would you interpret these results?
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Infecções por HIV , Teste de HIV , Humanos , Infecções por HIV/diagnóstico , Teste de HIV/métodosRESUMO
Background: During the 2022 mpox outbreak most patients were managed as outpatients, but some required hospitalization. Uncontrolled human immunodeficiency virus (HIV) has been identified as a risk factor for severe mpox. Methods: Patients with mpox diagnosed or treated within the Johns Hopkins Health System between 1 June and 15 December 2022 were included. The primary outcome of interest was risk of hospitalization. Demographic features, comorbid conditions, treatment, and clinical outcomes were determined. Results: A total of 353 patients were tested or treated for mpox; 100 had mpox diagnosed or treated (median age, 35.3 years; 97.0% male; 57.0% black and 10.0% Hispanic; 46.0% people with HIV [PWH]). Seventeen patients (17.0%) required hospitalization, 10 of whom were PWH. Age >40 years, race, ethnicity, HIV status, insurance status, and body mass index >30 (calculated as weight in kilograms divided by height in meters squared) were not associated with hospitalization. Eight of 9 patients (88.9%) with immunosuppression were hospitalized. Immunosuppression was associated with hospitalization in univariate (odds ratio, 69.3 [95% confidence interval, 7.8-619.7]) and adjusted analysis (adjusted odds ratio, 94.8 [8.5-1060.1]). Two patients (11.8%) who were hospitalized required intensive care unit admission and died; both had uncontrolled HIV infection and CD4 T-cell counts <50/µL. Median cycle threshold values for the first positive mpox virus sample did not differ between those who were hospitalized and those who were not. Conclusions: Immunosuppression was a significant risk factor for hospitalization with mpox. PWH with CD4 T-cell counts <50/µL are at high risk of death due to mpox infection. Patients who are immunosuppressed should be considered for early and aggressive treatment of mpox, given the increased risk of hospitalization.
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BACKGROUND: Telemedicine use for the care of people with HIV (PWH) significantly expanded during the COVID-19 pandemic. During 2021, vaccine uptake increased and patients were encouraged to resume in-person care, resulting in a mixture of in-person and telemedicine visits. We studied how different patient populations used telemedicine in this hybrid-care environment. METHODS: Using observational data from patients enrolled in the Johns Hopkins HIV Clinical Cohort, we analyzed all in-person and telemedicine HIV primary care visits completed in an HIV clinic from January 1st, 2021, to December 31st, 2021. We used log-binomial regression to investigate the association between patient characteristics and the probability of completing a telemedicine versus in-person visit and the probability of completing a video versus telephone visit. RESULTS: A total of 5518 visits were completed by 1884 patients; 4282 (77.6%) visits were in-person, 800 (14.5%) by phone, and 436 (7.9%) by video. The relative risk (RR) of completing telemedicine vs. in-person visits was 0.65 (95% Confidence Interval (CI): 0.47, 0.91) for patients age 65 years or older vs. age 20-39 years; 0.84 (95% CI: 0.72, 0.98) for male patients vs. female patients; 0.81 (95% CI: 0.66, 0.99) for Black vs. White patients; 0.62 (95% CI: 0.49, 0.79) for patients in the highest vs. lowest quartile of Area Deprivation Index; and 1.52 (95% CI: 1.26, 1.84) for patients >15 miles vs. <5 miles from clinic. CONCLUSIONS: In the second year of the pandemic, overall in-person care was used more than telemedicine and significant differences persist across subgroups in telemedicine uptake.
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COVID-19 , Infecções por HIV , Telemedicina , Humanos , Feminino , Masculino , Idoso , Adulto Jovem , Adulto , COVID-19/epidemiologia , Pandemias , Infecções por HIV/epidemiologia , Instituições de Assistência AmbulatorialRESUMO
BACKGROUND: During the COVID-19 pandemic, patients experienced significant care disruptions, including laboratory monitoring. We investigated changes in the time between viral load (VL) checks for people with HIV (PWH) associated with the pandemic. SETTING AND METHODS: This was an observational analysis of VLs of PWH in routine care at a large subspecialty clinic. At pandemic onset, the clinic temporarily closed its onsite laboratory. The exposure was time period (time varying): prepandemic (January 1, 2019-March 15, 2020); pandemic laboratory closed (March 16-July 12, 2020); and pandemic laboratory open (July 13-December 31, 2020). We estimated time from an index VL to a subsequent VL, stratified by whether the index VL was suppressed (≤200 copies/mL). We also calculated cumulative incidence of a nonsuppressed VL following a suppressed index VL, and of resuppression following a loss of viral suppression. RESULTS: Compared with prepandemic, hazard ratios for next VL check were 0.34 (95% CI: 0.30 to 0.37, laboratory-closed) and 0.73 (CI: 0.68 to 0.78, laboratory-open) for suppressed patients, and 0.56 (CI: 0.42 to 0.79, laboratory-closed) and 0.92 (95% CI: 0.76 to 1.10, laboratory-open) for nonsuppressed patients. The 12-month cumulative incidence of loss of suppression was the same in the pandemic laboratory-open (4%) and prepandemic (4%) period. The hazard of resuppression following the loss of suppression was lower during the pandemic laboratory-open versus the prepandemic period (hazard ratio: 0.68, 95% CI: 0.50 to 0.92). CONCLUSIONS: Early pandemic restrictions and laboratory closure significantly delayed VL monitoring. Once the laboratory reopened, nonsuppressed patients resumed normal monitoring. Suppressed patients still had a delay but no significant loss of suppression.
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Fármacos Anti-HIV , COVID-19 , Infecções por HIV , Instituições de Assistência Ambulatorial , Fármacos Anti-HIV/uso terapêutico , COVID-19/epidemiologia , Infecções por HIV/tratamento farmacológico , Humanos , Pandemias , Carga ViralRESUMO
In persons living with HIV-1 (PLWH) who start antiretroviral therapy (ART), plasma virus decays in a biphasic fashion to below the detection limit. The first phase reflects the short half-life (<1 d) of cells that produce most of the plasma virus. The second phase represents the slower turnover (t1/2 = 14 d) of another infected cell population, whose identity is unclear. Using the intact proviral DNA assay (IPDA) to distinguish intact and defective proviruses, we analyzed viral decay in 17 PLWH initiating ART. Circulating CD4+ T cells with intact proviruses include few of the rapidly decaying first-phase cells. Instead, this population initially decays more slowly (t1/2 = 12.9 d) in a process that largely represents death or exit from the circulation rather than transition to latency. This more protracted decay potentially allows for immune selection. After â¼3 mo, the decay slope changes, and CD4+ T cells with intact proviruses decay with a half-life of 19 mo, which is still shorter than that of the latently infected cells that persist on long-term ART. Two-long-terminal repeat (2LTR) circles decay with fast and slow phases paralleling intact proviruses, a finding that precludes their use as a simple marker of ongoing viral replication. Proviruses with defects at the 5' or 3' end of the genome show equivalent monophasic decay at rates that vary among individuals. Understanding these complex early decay processes is important for correct use of reservoir assays and may provide insights into properties of surviving cells that can constitute the stable latent reservoir.
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Antirretrovirais/farmacologia , Infecções por HIV/tratamento farmacológico , HIV-1/efeitos dos fármacos , Provírus/efeitos dos fármacos , Vírion/efeitos dos fármacos , Linfócitos T CD4-Positivos/efeitos dos fármacos , Células Cultivadas , DNA Viral/efeitos dos fármacos , Humanos , Estudos Longitudinais , Carga Viral/efeitos dos fármacos , Latência Viral/efeitos dos fármacos , Replicação Viral/efeitos dos fármacosRESUMO
OBJECTIVES: Telemedicine became the primary mode of delivering care during the COVID-19 pandemic. We describe the impact of telemedicine on access to care for people with HIV (PWH) by comparing the proportion of PWH engaged in care prior to and during the COVID-19 pandemic. DESIGN AND METHODS: We conducted an observational analysis of patients enrolled in the Johns Hopkins HIV Clinical Cohort, a single-center cohort of patients at an urban HIV subspecialty clinic affiliated with an academic center. Due to the COVID-19 pandemic, the clinic transitioned from in-person to mostly telemedicine visits. We compared patients receiving care in two time periods. The prepandemic period included 2010 people with at least one visit scheduled between 1 September 2019 and 15 March 2020. The pandemic period included 1929 people with at least one visit scheduled between 16 March 2020 and 30 September 2020. We determined the proportion of patients completing at least one of their scheduled visits during each period. RESULTS: Visit completion increased significantly from 88% prepandemic to 91% during the pandemic (Pâ=â0.008). Visit completion improved significantly for patients age 20-39 (82 to 92%, Pâ<â0.001), women (86 to 93%, Pâ<â0.001), Black patients (88 to 91%, Pâ=â0.002) and patients with detectable viremia (77 to 85%, Pâ=â0.06) during the pandemic. Only 29% of people who completed at least one telemedicine visit during the pandemic did so as a video (versus telephone) visit. CONCLUSION: During the pandemic when care was widely delivered via telemedicine, visit completion improved among groups with lower prepandemic engagement but most were limited to telephone visits.
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COVID-19 , Infecções por HIV , Telemedicina , Adulto , Feminino , Humanos , Pandemias , SARS-CoV-2 , Adulto JovemAssuntos
Fármacos Anti-HIV/administração & dosagem , Prescrições de Medicamentos/estatística & dados numéricos , Infecções por HIV/prevenção & controle , Profilaxia Pré-Exposição/métodos , Encaminhamento e Consulta/estatística & dados numéricos , Adolescente , Adulto , Fármacos Anti-HIV/uso terapêutico , Serviço Hospitalar de Emergência/estatística & dados numéricos , Feminino , Infecções por HIV/tratamento farmacológico , Humanos , Masculino , Pessoa de Meia-Idade , Profilaxia Pré-Exposição/estatística & dados numéricos , Adulto JovemRESUMO
BACKGROUND: People living with human immunodeficiency virus (HIV) may have numerous risk factors for acquiring coronavirus disease 2019 (COVID-19) and developing severe outcomes, but current data are conflicting. METHODS: Health-care providers enrolled consecutively, by nonrandom sampling, people living with HIV (PWH) with lab-confirmed COVID-19, diagnosed at their facilities between 1 April and 1 July 2020. Deidentified data were entered into an electronic Research Electronic Data Capture (REDCap) system. The primary endpoint was a severe outcome, defined as a composite endpoint of intensive care unit (ICU) admission, mechanical ventilation, or death. The secondary outcome was the need for hospitalization. RESULTS: There were 286 patients included; the mean age was 51.4 years (standard deviation, 14.4), 25.9% were female, and 75.4% were African American or Hispanic. Most patients (94.3%) were on antiretroviral therapy, 88.7% had HIV virologic suppression, and 80.8% had comorbidities. Within 30 days of testing positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), 164 (57.3%) patients were hospitalized, and 47 (16.5%) required ICU admission. Mortality rates were 9.4% (27/286) overall, 16.5% (27/164) among those hospitalized, and 51.5% (24/47) among those admitted to an ICU. The primary composite endpoint occurred in 17.5% (50/286) of all patients and 30.5% (50/164) of hospitalized patients. Older age, chronic lung disease, and hypertension were associated with severe outcomes. A lower CD4 count (<200 cells/mm3) was associated with the primary and secondary endpoints. There were no associations between the ART regimen or lack of viral suppression and the predefined outcomes. CONCLUSIONS: Severe clinical outcomes occurred commonly in PWH with COVID-19. The risks for poor outcomes were higher in those with comorbidities and lower CD4 cell counts, despite HIV viral suppression. CLINICAL TRIALS REGISTRATION: NCT04333953.
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COVID-19 , Infecções por HIV , Idoso , Feminino , HIV , Infecções por HIV/tratamento farmacológico , Infecções por HIV/epidemiologia , Hospitalização , Humanos , Pessoa de Meia-Idade , Sistema de Registros , SARS-CoV-2RESUMO
Panoramic radiography is a useful screening tool for an array of dental and nonodontogenic disorders related to calcification as well as assessment of trauma and development of the oral and maxillofacial complex. Rotational movements of the radiographic source and detector plate may promote ghost image formation, particularly with larger radiopaque objects, and complicate the radiographic interpretation. This article describes cases of a giant submandibular gland sialolith and a giant tonsillolith, each of which appeared as a bilateral presentation due to contralateral ghost images, and discusses their clinical, demographic, and radiographic characteristics. Computed tomographic examinations were used to confirm the unilateral presentation of these objects and for determination of the extent of adjacent soft tissue impingement. Distinguishing an actual panoramic image from a ghost artifact may avoid unnecessary surgical intervention and improve clinical outcomes.
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Cálculos das Glândulas Salivares , Humanos , Exame Físico , Radiografia Panorâmica , Tomografia Computadorizada por Raios XRESUMO
Although there appears to be an overall trend of diminishing oral manifestations of HIV infection, evidence is emerging on the increased incidence of concomitant parotid gland enlargement and xerostomia. Furthermore, several case narrations and a limited series have suggested a possible association of sialolithiasis with highly active antiretroviral therapy, mostly involving the parotid gland. The aim of this report is to present a patient with a giant sialolith of the submandibular gland following a 27-year intake of various antiretrovirals for HIV infection and review the relevant literature.