Beyond the HIV Care Continuum and Viral Suppression: Broadening the Scope of Quality Metrics for Total HIV Patient Care.

Assessing quality care for people with HIV (PWH) should not be limited to reporting on HIV Care Continuum benchmarks, particularly viral suppression rates. At Kaiser Permanente Mid-Atlantic States (KPMAS), an integrated health system providing HIV care in the District of Columbia, Maryland, and Virginia, we created a comprehensive measure of HIV quality care, including both preventative measures and clinical outcomes. We included PWH ≥18 years old with ≥6 months KPMAS membership between 2015 and 2018. Process quality metrics (QMs) include: pneumococcal vaccination and influenza vaccination; primary care physician (PCP) and/or HIV/infectious disease (HIV/ID) visits with additional HIV/ID visit; antiretroviral treatment medication fills; and syphilis and gonorrhea/chlamydia screenings. Outcome QMs include HIV RNA <200/mL and other measurements within normal range [blood pressure, body mass index (BMI), hemoglobin, blood sugar, alanine transaminase, low-density lipoproteins, estimated glomerular filtration rate]; no hospitalization/emergency department visit; no new depression diagnosis; remaining or becoming a nonsmoker. Logistic models estimated odds of achieving QMs associated with sex, age, race/ethnicity, insurance type, and HIV risk. A total of 4996 observations were analyzed. 45.6% met all process QMs, while 19.6% met all outcome QMs. Least frequently met process QM was PCP or HIV/ID visit (74.5%); least met outcome QM was BMI (60.2%). Significantly lower odds of achieving all QMs among women {odds ratio (OR) = 0.63 [95% confidence interval (CI): 0.49-0.81]} and those with Medicaid and Medicare [vs. commercial; OR = 0.48 (95% CI: 0.30-0.76) and 0.47 (95% CI: 0.31-0.71)]. Broadening the scope of HIV patient care QMs beyond viral suppression helps identify opportunities for improvement. Successful process metrics do not necessarily coincide with greater outcome metrics.

Looming Vulnerability and Smoking Cessation Attempts.

INTRODUCTION: The looming vulnerability model holds that people become anxious when they perceive threats as growing larger and accelerating toward them in space and time. Preliminary research suggested that a guided imagery induction designed to activate a sense that health consequences of smoking are a looming threat led more smokers to attempt to quit. This study tested the effect on quit attempts in a larger sample and examined age, sex, and sensation seeking as moderators. AIMS AND METHODS: Adult smokers (≥10 cigarettes/day) screened for risk of anxiety or mood disorders (N = 278, 52% male; 77% African American) were randomly assigned to receive (1) looming vulnerability or (2) neutral guided imagery exercises. At a 4-week follow-up, they reported quit attempts, smoking rate, self-efficacy, outcome expectancies, and contemplation status. RESULTS: Those in the looming condition (17%) were no more likely than those in the control condition (20%) to make a quit attempt. There were no significant group differences in expectancies, contemplation, or follow-up smoking rate, and no significant moderators. CONCLUSIONS: The looming induction was the same one used in earlier work in which it had stronger effects. Those who respond to it with increased urgency about quitting smoking might be offset by others who are more reactant and deny the message. Inconsistencies across studies may reflect differences in inclusion criteria, such that the present sample was on average heavier smokers with longer smoking history and more severe nicotine dependence, yet higher self-efficacy. IMPLICATIONS: An induction designed to activate a sense that the health consequences of smoking constitute a looming vulnerability failed to increase quit attempts or reduce smoking rate among adult daily smokers. Inconsistencies across studies might reflect varying sample characteristics resulting from changes in screening criteria.

Antiretroviral Treatment Interruptions Among Black and Latina Transgender Women Living with HIV: Characterizing Co-occurring, Multilevel Factors Using the Gender Affirmation Framework.

Black and Latina transgender women (BLTW) are disproportionately impacted by HIV but remain underrepresented in HIV and health services research. Between March 2016 and May 2017, BLTW (N = 201) were recruited in Baltimore, Maryland and Washington, DC through convenience sampling for a survey assessing multilevel determinants of HIV risk and treatment outcomes. Interviews concluded with a rapid oral HIV test. Bivariate and multivariable logistic regression modeling was performed to identify gender affirmation-related correlates of self-reported HIV treatment interruptions (HIVTIs) among BLTW living with HIV who had initiated antiretroviral therapy (ART) (n = 96). Among them, 57.3% (n = 55) reported at least one HIVTI. Unmet surgical needs (aOR = 1.6), past-year marijuana use (aOR = 14.6), and no current hormone use (aOR = 24.9) were significantly (p < 0.05) associated with HIVTIs in multivariable analysis. Unmet need for gender affirmation may inhibit ART adherence, highlighting opportunities to mitigate care interruptions in alignment with community needs and goals.

Quality Metrics and Health Care Utilization for Adult Patients with Sickle Cell Disease.

BACKGROUND: To date, there are no standardized, well-accepted, quality metrics that guide care for adults with sickle cell disease (SCD). The primary objective of this study was to evaluate the quality metrics that are in use at the Adult Sickle Cell Disease Program at Johns Hopkins Hospital (JHH) and the applicability of the metrics to Kaiser Permanente Mid-Atlantic States (KPMAS), an integrated healthcare system with a developing adult sickle cell disease program. METHODS: We performed a retrospective cross-sectional study of 146 KPMAS and 308 JHH patients from January 1, 2014-December 31, 2015. Demographics, genotype and data on several key quality metrics (yearly screening labs, documented vaccinations and appropriate hydroxyurea prescriptions) were collected from electronic health records (EPIC Systems). We defined hydroxyurea adherence as having had at least 6 months of refills prescribed during the two years of study by either EHR or patient report. RESULTS: Patients at KPMAS were older than those at JHH (median age 44 and 33 respectively) and less likely to have hemoglobin SS disease (29% and 66% respectively). Among KPMAS patients, 85% had documentation of any pneumococcal vaccination compared to 87% at JHH. 21 of 54 eligible patients at KPMAS and 95 of 165 eligible patients at JHH were prescribed hydroxyurea. At both institutions, 62% of patients were adherent to hydroxyurea. There were limitations to diagnosis coding and availability of vaccination and refill documentation. CONCLUSIONS: Interventions to improve preventative care adherence are needed to improve outcomes in both academic medical centers and integrated health systems.

Biochemical and clinical deficiency is uncommon in African immigrants despite a high prevalence of low vitamin D: the Africans in America study.

UNLABELLED: African ancestry is associated with low vitamin D levels but high bone density. Fifty percent of African immigrants had low vitamin D levels, but <10 % had evidence of deficiency. The value of providing vitamin D supplementation to African immigrants without evidence of deficiency needs to be determined. INTRODUCTION: The Endocrine Society and Institute of Medicine (IOM) have concluded from studies in largely white populations that 25(OH)D is necessary for bone health. However, their definition of vitamin D insufficiency differs. The Endocrine Society recommends a 25(OH)D threshold of <30 ng/mL. The IOM uses a lower threshold of 25(OH)D of <20 ng/mL. As African ancestry is associated with decreased 25(OH)D but increased bone mineral density (BMD), the applicability of these thresholds to Africans is unknown. Therefore, we examined in African immigrants the relationship of 25(OH)D to parathyroid hormone (PTH) and BMD. METHODS: One hundred eighty-six African immigrants(69 % male, age 38 ± 10 (mean ± SD), range 20-64 years) living in metropolitan Washington, DC, were enrolled. BMD was determined from whole-body dual-energy X-ray absorptiometry (DXA) scans. Decreased BMD required T-scores ≤-1.0. The threshold for low 25(OH)D was the concentration of 25(OH)D at which PTH became suppressed. This is known as the inflection point. Biochemical deficiency required low 25(OH)D and PTH of >65 pg/mL. Clinical deficiency required low 25(OH)D and T-scores ≤-1.0. RESULTS: 25(OH)D <30 and <20 ng/mL occurred in 83 and 46 % of African immigrants, respectively. PTH inversely correlated with 25(OH)D (r = -0.31, P = 0.002). The inflection point occurred at a 25(OH)D concentration of 20 ng/mL. Biochemical and clinical deficiency occurred in only 8 and 3 % of immigrants, respectively. CONCLUSION: As PTH became suppressed at 25(OH)D of 20 ng/mL, the 25(OH)D <20 ng/mL threshold for insufficiency may apply to African immigrants. However, ~50 % of African immigrants have 25(OH)D <20 ng/mL, but only <10 % had evidence of deficiency. The value of providing vitamin D supplementation to the large number of African immigrants with 25(OH)D <20 ng/mL and no detectable evidence of deficiency needs to be determined.

Characteristics, management, and depression outcomes of primary care patients who endorse thoughts of death or suicide on the PHQ-9.

BACKGROUND: With increasing emphasis on integrating behavioral health services, primary care providers play an important role in managing patients with suicidal thoughts. OBJECTIVE: To evaluate whether Patient Health Questionnaire-9 (PHQ-9) Item 9 scores are associated with patient characteristics, management, and depression outcomes in a primary care-based mental health program. DESIGN: Observational analysis of data collected from a patient registry. PARTICIPANTS: Eleven thousand fifteen adults enrolled in the Mental Health Integration Program (MHIP). INTERVENTIONS: MHIP provides integrated mental health services for safety-net populations in over 100 community health centers across Washington State. Key elements of the team-based model include: a disease registry; integrated care management; and organized psychiatric case review. MAIN MEASURES: The independent variable, suicidal ideation (SI), was assessed by PHQ-9 Item 9. Depression severity was assessed with the PHQ-8. Outcomes included four indicators of depression treatment process (care manager contact, psychiatric case review, psychotropic medications, and specialty mental health referral), and two indicators of depression outcomes (50 % reduction in PHQ-9 score and PHQ-9 score < 10). KEY RESULTS: SI was common (45.2 %) at baseline, with significantly higher rates among men and patients with greater psychopathology. Few patients with SI (5.4 %) lacked substantial current depressive symptoms. After adjusting for age, gender, and severity of psychopathology, patients with SI received follow-up earlier (care manager contact HR = 1.05, p < 0.001; psychiatric review HR = 1.02, p < 0.05), and were more likely to receive psychotropic medications (OR = 1.11, p = 0.001) and specialty referral (OR = 1.23, p < 0.001), yet were less likely to achieve a PHQ-9 score < 10 (HR = 0.87, p < 0.001). CONCLUSIONS: Suicidal thoughts are common among safety-net patients referred by primary care providers for behavioral health care. Scores on Item 9 of the PHQ-9 are easily obtainable in primary care, may help providers initiate conversations about suicidality, and serve as useful markers of psychiatric complexity and treatment-resistance. Patients with positive scores should receive timely and comprehensive psychiatric evaluation and follow-up.

An integrated randomized intervention to reduce behavioral and psychosocial risks: pregnancy and neonatal outcomes.

While biomedical risks contribute to poor pregnancy and neonatal outcomes in African American (AA) populations, behavioral and psychosocial risks (BPSR) may also play a part. Among low income AA women with psychosocial risks, this report addresses the impacts on pregnancy and neonatal outcomes of an integrated education and counseling intervention to reduce BPSR, as well as the contributions of other psychosocial and biomedical risks. Subjects were low income AA women ≥18 years living in the Washington, DC, metropolitan area and seeking prenatal care. Subjects (n = 1,044) were screened for active smoking, environmental tobacco smoke exposure (ETSE), depression, or intimate partner violence (IPV) and then randomized to intervention (IG) or usual care (UCG) groups. Data were collected prenatally, at delivery, and postpartum by maternal report and medical record abstraction. Multiple imputation methodology was used to estimate missing variables. Rates of pregnancy outcomes (miscarriage, live birth, perinatal death), preterm labor, Caesarean section, sexually transmitted infection (STI) during pregnancy, preterm birth (<37 weeks), low birth weight (<2,500 g), very low birth weight (<1,500 g), small for gestational age, neonatal intensive care unit (NICU) admission, and >2 days of hospitalization were compared between IG and UCG. Logistic regression models were created to predict outcomes based on biomedical risk factors and the four psychosocial risks (smoking, ETSE, depression, and IPV) targeted by the intervention. Rates of adverse pregnancy and neonatal outcomes were high and did not differ significantly between IG and UCG. In adjusted analysis, STI during the current pregnancy was associated with IPV (OR = 1.41, 95% CI 1.04-1.91). Outcomes such as preterm labor, caesarian section in pregnancy and preterm birth, low birth weight, small for gestational age, NICU admissions and >2 day hospitalization of the infants were associated with biomedical risk factors including preexisting hypertension and diabetes, previous preterm birth (PTB), and late initiation of prenatal care, but they were not significantly associated with active smoking, ETSE, depression, or IPV. Neither the intervention to reduce BPSR nor the psychosocial factors significantly contributed to the pregnancy and neonatal outcomes. This study confirms that biomedical factors significantly contribute to adverse outcomes in low income AA women. Biomedical factors outweighed psychosocial factors in contributing to adverse pregnancy and neonatal outcomes in this high-risk population. Early identification and management of hypertension, diabetes and previous PTB in low income AA women may reduce health disparities in birth outcomes. Level of evidence I.

Adult asthma exacerbations and environmental triggers: a retrospective review of ED visits using an electronic medical record.

BACKGROUND: Despite familiarity with triggers for asthma, there is little recent study on the association of triggers with the emergency department (ED) presentation of adult asthma exacerbation. METHODS: Retrospective electronic chart review of adult patients treated in an urban teaching hospital ED with chief complaint and diagnostic coding related to asthma and upper respiratory tract infection (URI) was conducted. Monthly aeroallergen data and environmental conditions were obtained from a local allergen extract laboratory and local government sources. Data analysis was performed using Newey-West time series regression modeling with adjustment for autocorrelation or ordinary least squares linear regression modeling using outcome variables of asthma visits and admissions. RESULTS: There were 56, 747 visits, with 554 asthma visits and 1,514 URI visits. Asthma visits (R(2) = 0.631) were positively correlated with tree pollen counts (correlation coefficient = 0.458 [0.152-0.765]) and average humidity (correlation coefficient = 1.528 [0.296-2.760]). Asthma admissions (R(2) = 0.480) were negatively correlated with average temperature (correlation coefficient = -0.557 [-1.052 to -0.061]) when adjusting for confounding by fine particulate matter. CONCLUSIONS: The ED acute asthma exacerbation presentation is positively correlated with tree pollen and humidity, whereas need for admission is associated with dropping temperatures. These results reinforce the need for vigilance during periods of increased risk and perhaps focused preventative strategies.

Comparing models of maternity care serving women at risk of poor birth outcomes in Washington, DC.

Low-income African American women in Washington, DC, exhibit some of the worst birth outcomes in the United States. The authors undertook a qualitative, comparative case study of three different models of maternity care delivery to low-income women at risk of poor birth outcomes in Washington. The key study objectives were (1) to describe the organization, delivery, and content of care of the three models of maternity care and (2) to analyze how the models of care might be improved to better serve this population efficiently and cost-effectively. Our results indicate that all three models vary distinctly in how they organize and deliver care and what composes the content of care. Further, findings suggest that pregnant low-income women require the allocation of additional and nontraditional maternity care resources such as prenatal group care and breastfeeding peer counselors. These nontraditional components of care help providers address underlying social risk factors that may be negatively affecting the health of pregnant women and their unborn children. While nontraditional maternity care models may provide greater value for money than traditional obstetric models, they face funding and sustainability challenges.

The Family Health and Birth Center--a nurse-midwife-managed center in Washington, DC.

The Family Health and Birth Center (FHBC) is a family- and community-centered collaborative partnership designed to address the needs of women and families in the geographic area known as Ward 5 in Washington, DC. This community is predominantly low-income and African American; however, in recent years, a growing Latina and middle-income white population have sought out FHBC's services. Based on the midwifery model, FHBC provides prenatal care and midwifery-supported and -attended births in the freestanding birth center or at the nearby Washington Hospital Center. Through the collaborative partnership housed in a former supermarket and known as the Developing Families Center (DFC), FHBC works closely with the Healthy Babies Project and the United Planning Organization's Early Childhood Development Center. The aim of these partnerships is to provide midwifery-supported prenatal and birthing care within a framework of understanding the social context of health care. Together, the DFC/FHBC collaborative partnership provides a comprehensive system of health care for this predominantly underserved population. The purpose of this article is to highlight the FHBC--our perspective on the history of the founding of this center as a nurse-midwife-led model of care. Included in this issue is a comparative case study conducted by Palmer et al at the Urban Institute that systematically contrasts the care provided by three different models of maternity care serving low-income African American women in Washington, DC. Using qualitative methodology, the study analyzes the content and delivery of care, and the cost-effectiveness of FHBC as compared to a large city hospital and a federally qualified health care center. Study findings indicate that the combined elements of nurse-midwife-led maternal and child care with a focus on the social and educational context of pregnancy, birth, and infant/toddler better meet the needs of the population than do the comparison models.

Outbreak of mesotherapy-associated skin reactions--District of Columbia area, January-February 2005.

Mesotherapy is a treatment involving local subcutaneous injections of minute quantities of various substances (e.g., vitamins or plant extracts) for cosmetic purposes (e.g., fat and wrinkle reduction or body contouring) or relief of musculoskeletal pain. In February 2005, the Virginia Department of Health and CDC were notified of a cluster of skin reactions unresponsive to antimicrobial therapy among patients who had been administered mesotherapy by an unlicensed practitioner in the District of Columbia (DC) area. This report 1) summarizes the subsequent investigation by CDC and state and local health departments in Virginia, Maryland, and DC, which identified prolonged skin reactions in 14 patients, and 2) provides recommendations for practices related to mesotherapy. Patients should accept medical therapy only from licensed practitioners and should not permit injection of substances that have not been approved by the Food and Drug Administration (FDA). Licensed practitioners should follow safe-injection practices when practicing mesotherapy and patients should observe that safe-injection practices are followed.

Do sociocultural factors predict suicidality among persons of African descent living in the U.S.?

Given that researchers have found increased risk for suicidality and other psychiatric problems among acculturated individuals, we predicted similar results for African-descended people living in the U.S. We surveyed a community sample of 423 adult men and women of African descent to determine acculturation's relationship to Black suicide. Participants completed the African American Acculturation Scale, the Multi-Dimensional Support Scale, and a subscale of the Spiritual Well-Being Scale. Suicidal ideation and history of suicide attempt were defined as a "yes" response to the questions, "have you ever considered taking your own life?" and "have you ever attempted to take your own life?" We found that religious well-being (not acculturation) was predictive of both suicidal ideation and history of suicide attempt.

Bone mass in physicians: a Howard University Hospital pilot study.

PURPOSE: This observational cross-sectional study was done to determine bone mass in physicians and to determine if variables, such as calcium intake and exercise, were related to their bone mass. METHODS: One-hundred physicians of different ethnicities (African, African American, Asian, Caribbean, and Hispanic) were studied. Using dual-energy x-ray absorptiometry (DEXA), bone mass (BMD) of the lumbar spine and hips was measured. A validated questionnaire was used to determine the daily calcium intake and exercise. Student t-test, logistic regression, and Pearson chi-square were used to analyze the data. RESULTS: The study population consisted of 52% men and 48% women, with a mean age of 42 years old and a body mass index of 18.5 to 39.9 kg/m2. Low BMD occurred in 68% of the physicians (osteoporosis in 12%, osteopenia in 56%). Low calcium intake was found in 71%-14% of whom had osteoporosis and 49% osteopenia. Two-thirds of the physicians had inadequate exercise; 57% of this group had decreased BMD (osteoporosis in 9%, osteopenia in 38%). There was no statistical significance between BMD and calcium intake or exercise. CONCLUSION: A high percentage of the physicians in this unique study had a reduced BMD. Most of the physicians with low BMD were less than 45 years of age. This study indicates the need to define BMD in a larger cohort of young, ethnically diverse clinicians, and other health workers.

Outcomes of high-risk women cared for by certified nurse-midwives.

This study describes the incidence of specific high-risk factors of a population cared for by a group of certified nurse-midwives (CNMs) in a Mid-Atlantic, inner-city, nonprofit, hospital-based clinic. Outcomes were compared with all women who delivered in the United States in 1994. Univariate statistics, which consisted of descriptive statistics, frequencies, and percentage distribution, were used. This comparison suggests that CNMs can provide safe care to women with high-risk conditions. Outcomes for the midwifery sample were more favorable for vaginal births, vaginal deliveries after cesarean section, forceps- and vacuum-assisted deliveries, cesarean delivery, and 5-minute Apgar scores. The incidence of maternal fever and meconium stained amniotic fluid was higher. Implications and limitations of the study are discussed.

Update: Investigation of bioterrorism-related anthrax and interim guidelines for exposure management and antimicrobial therapy, October 2001.

Since October 3, 2001, CDC and state and local public health authorities have been investigating cases of bioterrorism-related anthrax. This report updates previous findings, provides new information on case investigations in two additional areas, presents the susceptibility patterns of Bacillus anthracis isolates, and provides interim recommendations for managing potential threats and exposures and for treating anthrax.

High prevalence of alcoholism in dialysis patients.

Alcoholism is one of the most common psychosocial disorders, affecting approximately 10% of the general population. The impact of alcoholism on the care of patients with other medical illnesses has not been addressed in many of these populations, including patients with end-stage renal disease (ESRD) undergoing hemodialysis. We set out to determine the prevalence of alcoholism in an urban hemodialysis population and ascertain whether alcoholism had an effect on compliance in this population. One hundred sixty-three urban hemodialysis patients were screened using the Michigan Alcoholism Screening Test (MAST), a 25-item questionnaire that has been validated in multiple trials. Forty-five patients (27.6%) scored 5 or greater on the MAST. The MAST-positive subjects were younger (age, 55 +/- 15 years versus 64 +/- 13 years) and tended to be men (58% versus 43%). There was no significant difference in the incidence of diabetic kidney disease; however, there were significantly more human immunodeficiency virus (HIV)-positive patients in the MAST-positive group. The dietary compliance measures of predialysis potassium or phosphorus levels did not differ between the two groups. A trend toward lower serum albumin level was evident in the men in the MAST-positive group (3.75 +/- 0.57 versus 3.91 +/- 0.30 g/dL; P = 0.0212). In conclusion, there is a high prevalence of alcoholism in the urban dialysis population. Alcoholic patients with ESRD are younger and tend to be men. HIV-positive patients with ESRD have a high prevalence of concomitant alcoholism. Compliance indicators of predialysis potassium and phosphorus levels are not affected. However, nutritional status, measured by serum albumin level, tends to be poorer in the alcoholic group.

Predominant tree aeroallergens of the Washington, DC area: a six year survey (1989-1994).

OBJECTIVE: A 6-year (1989 to 1994) aerobiologic survey of the Washington DC area was performed to identify predominant area tree pollens, atmospheric concentrations, and peak flowering periods. METHODS: Aeroallergen sampling was conducted using a volumetric rotating-arm impaction Rotorod sampler (Sampling Technologies, Inc, Los Altos Hills, California). RESULTS: The Washington DC pollen calendar may begin as early as January when pollen of the Cupresseacea, Aceracea, Pinaceae, and Betulaceae are observed in small amounts. February through June encompasses the major part of our tree season with considerable overlapping of pollination periods for various trees. The Ulmaceae have two distinct pollinating times with later flowering species of elm pollinating August through October coinciding with ragweed season. April is usually the month with the highest weekly average concentrations. Each year oaks contribute more than 50% of the total tree pollen count followed by pollen of the Pinacea, Cupresseacea, Moracea, and Betuleacea. Times for onset of pollination as well as peak atmospheric concentrations varied from year to year. High production years for some tree aeroallergens are low years for others. CONCLUSION: The Washington DC area is exposed to significant atmospheric concentrations of tree pollen from February through June. Establishing what area tree aeroallergens predominate with respect to their atmospheric concentrations and peak pollinating times is essential for the effective diagnosis and treatment of the tree-allergic patient.

Dietary micronutrient intake and risk of progression to acquired immunodeficiency syndrome (AIDS) in human immunodeficiency virus type 1 (HIV-1)-infected homosexual men.

The authors sought to determine if different levels of dietary intake of micronutrients are associated with the progression of human immunodeficiency virus type 1 (HIV-1) infection to acquired immunodeficiency syndrome (AIDS). A total of 281 HIV-1 seropositive homosexual/bisexual men were seen semiannually since 1984 at the Baltimore/Washington, DC site of the Multicenter AIDS Cohort Study. Participants completed a self-administered semiquantitative food frequency questionnaire at baseline. Levels of daily micronutrient intake at baseline were examined in relation to subsequent progression to AIDS (1987 Centers for Disease Control definition; n = 108) during a median follow-up period of 6.8 years. For each nutrient, the authors used a Cox proportional hazards model to adjust for age, presence of symptoms, CD4+ lymphocyte count, energy intake, use of antiretrovirals, and use of Pneumocystis carinii pneumonia prophylaxis. The highest levels of total intake (from food and supplements) of vitamins C and B1 and niacin were associated with a significantly decreased progression rate to AIDS: vitamin C (relative hazard (RH) = 0.55, 95% confidence interval (CI) 0.34-0.91), vitamin B1 (RH = 0.60, 95% CI 0.36-0.98), and niacin (RH = 0.52, 95% CI 0.31-0.86). The relation between total vitamin A intake and progression to AIDS appeared to be U-shaped; the lowest and highest quartiles of intake did most poorly, while the middle two quartiles were associated with significantly slower progression to AIDS (RH = 0.55, 95% CI 0.35-0.88). Increased intake of zinc was monotonically and significantly associated with an increased risk of progression to AIDS (for highest vs. lowest quartiles, RH = 2.06, 95% CI 1.16-3.64). In a final multinutrient model, vitamin A, niacin, and zinc remained significantly associated with progression to AIDS, while vitamin C was only marginally significant.