Early Presence of HIV-1 Subtype C in Washington, D.C.

The presence of non-B HIV subtypes in the USA has been documented during the epidemic, although the timing of early introductions of different subtypes remains uncertain. Subtype C, the most common HIV variant worldwide, was first reported in the USA in 1996-97, after subtype C had expanded greatly in sub-Saharan Africa. In this study, we report a patient with subtype C infection acquired by mother-to-child transmission, born in the USA in 1990 to a Washington, D.C. resident who never traveled outside the USA, demonstrating that subtype C was present in the USA much earlier. Comparative analysis of the sequence from this patient and subtype C sequences in the USA and elsewhere suggest multiple independent introductions of this subtype into the USA have taken place, many of which are traced to sub-Saharan or East Africa. These data indicate subtype C HIV was already present in the USA years earlier than previously reported, and during the early period of subtype C expansion.

Clinically Indicated Corticosteroids Do Not Affect Bone Turnover During Immune Restoration of Severely Lymphopenic HIV-Infected Patients.

UNLABELLED: Lymphopenia, corticosteroids, antiretroviral therapy (ART), and inflammation negatively impact bone turnover and decrease bone mineral density, but their combined effect has not been evaluated. We examined the association between corticosteroids on bone turnover markers in severely lymphopenic HIV-infected patients initiating ART. Levels of osteocalcin (bone formation marker) and C-terminal telopeptide (CTX; bone resorption marker) were measured at baseline, weeks 4, 12, and 48 of ART in individuals with severe lymphopenia and opportunistic infection (OI) who received (n=28) or did not receive corticosteroids (n=30) during the first year of ART, and in a control group with CD4 >200 (n=15). Wilcoxon tests were used to compare median values of variables between groups. Correlations between plasma interleukin (IL)-6 and tumor necrosis factor (TNF) levels with bone turnover marker levels were performed using Spearman's coefficient. Individuals given corticosteroids received a median of 21 days at a 35 mg prednisone-equivalent daily dose. Individuals with severe lymphopenia had lower osteocalcin levels at baseline and week 4 and higher CTX levels at ART initiation vs. CONTROLS: Bone turnover markers did not differ in severely lymphopenic persons according to corticosteroid receipt. In those with severe lymphopenia, higher IL-6 was associated with higher CTX levels at ART initiation only. HIV-infected patients with severe lymphopenia and OI had lower levels of bone formation and higher levels of bone resorption than those initiating ART at higher CD4. Corticosteroid use, as prescribed during OI, was not associated with bone turnover. In contrast, higher markers of systemic inflammation prior to ART were associated with greater bone resorption.

A nurse-run walk-in clinic: cost-effective alternative to non-urgent emergency department use by the uninsured.

Non-urgent healthcare problems are responsible for more than 9 million visits to the emergency department (ED) in US hospitals each year, largely due to patients' lack of access to a primary care physician. To avoid costly and unnecessary ED usage for non-urgent health problems, a walk-in clinic run by nurses (CHEER Clinic) was developed as an extension of the services provided by an existing free clinic in a low-income neighborhood of Providence, RI, with the goal of providing uninsured patients with a convenient, no-cost means of accessing healthcare. An evaluation and cost-effectiveness analysis of the clinic's first 5 months of operation were performed. During this pilot period, 256 patients were seen. When incorporating the quality-adjusted-life-year value of preventive services rendered, an estimated $1.28 million in future healthcare costs was avoided. Dividing these cost-savings by the clinic's operational cost yielded a mean return on investment of $34 per $1 invested. Adding nurse-run walk-in hours at a free clinic significantly expanded access to healthcare for uninsured patients and was cost-effective for both the clinic and the patient. Ultimately, replication of this model in community clinics serving the uninsured could reduce ED burden by treating a substantial number of non-urgent medical concerns at a lower cost than would be incurred for treatment of the same problems in EDs.