Racial/ethnic differences in impact of gestational weight gain on interconception weight change.

Describe the association between gestational weight gain (GWG) and interconception weight change within race/ethnic groups, and differences across them. Data are from linked New York City birth certificates 1994-2004. The sample comprised nulliparous women ages ≥18 with two consecutive singleton births (N = 115,651). The dependent variable was interconception weight change. Adjusted analyses were from ordinary least squares regression model fully interacted by race/ethnic group, controlling for covariates. Within race/ethnic groups, adjusted interconception weight change was calculated for each GWG level compared with GWG 20-24 pounds; across groups, weight change was calculated for each group compared with white non-Hispanics. GWG ≥40 pounds was 18 % for Asian Pacific Islanders, and 27-29 % for other race/ethnic groups. Interconception weight change >15 pounds was highest for black non-Hispanics (34 %) and lowest for Asian Pacific Islanders (17 %). In the multivariable analysis, mean interconception weight change increased with increasing GWG in all race/ethnic groups, an average of 1.5-1.6 pounds for each 5-pound GWG interval. Compared with white non-Hispanics, adjusted mean interconception weight change was higher at every GWG level for black non-Hispanics (3.5-5.1 pounds), and at every level except <15 pounds for Hispanics (1.6-3.0 pounds). GWG ≥40 pounds was prevalent in all groups. GWG contributes to long-term interconception weight change, and non-Hispanic blacks and Hispanics are at risk of greater weight change. Interventions at many levels, during and after pregnancy, are needed to support women to achieve healthy GWG and postpartum weight loss.

Excess mortality among injection drug users with AIDS, New York City (1999-2004).

We calculated proportions and trends in contributing causes of death among persons with AIDS (PWA) and a history of injection drug use (IDU) in New York City and compared the proportions with those among PWA with a transmission risk of high-risk heterosexual sex (HRH) and men who have sex with men (MSM). We included all 10,575 injection drug user, HRH, and MSM residents aged 13+ years with AIDS reported by September 30, 2006 , who died from 1999 through 2004. Accidental drug overdose was the most frequent contributing cause of death among IDUs (20.5%). Overdose prevention initiatives may greatly and immediately reduce deaths among PWA.

Severity of 2009 pandemic influenza A (H1N1) virus infection in pregnant women.

OBJECTIVE: To examine 2009 H1N1 influenza illness severity and the effect of antiviral treatment on the severity of illness among pregnant women. METHODS: We abstracted medical records from hospitalized pregnant (n=62) and nonpregnant (n=74) women with laboratory-confirmed 2009 H1N1 influenza in New York City, May through June 2009. We compared characteristics of pregnant and nonpregnant women and of severe and moderate influenza illness among pregnant women, with severe defined as illness resulting in intensive care admission or death. RESULTS: The 2009 H1N1 hospitalization rate was significantly higher among pregnant than nonpregnant women (55.3 compared with 7.7 per 100,000 population). Eight pregnant (including two deaths) and 16 nonpregnant (including four deaths) cases were severe. Pregnant women represented 6.4% of hospitalized cases and 4.3% of deaths caused by 2009 H1N1 influenza. Only 1 in 30 (3.3%) pregnant women who received oseltamivir treatment within 2 days of symptom onset had severe illness compared with 3 of 14 (21.4%) and four of nine (44.4%) pregnant women who started treatment 3-4 days and 5 days or more after symptom onset, respectively (P=.002 for trend). Severe and moderate 2009 H1N1 influenza illness occurred in all pregnancy trimesters, but most women (54.8%) were in the third trimester. Twenty-two women delivered during their influenza hospitalization, and severe neonatal outcomes (neonatal intensive care unit admission or death) occurred among five of six (83.3%) women with severe illness compared with 2 of 16 (12.5%) women with moderate illness (P=.004). CONCLUSION: Our findings highlight the potential for severe illness and adverse neonatal outcomes among pregnant 2009 H1N1 influenza-infected women and suggest the benefit of early oseltamivir treatment. LEVEL OF EVIDENCE: II.

Comparing the National Death Index and the Social Security Administration's Death Master File to ascertain death in HIV surveillance.

OBJECTIVES: New York City (NYC) maintains a population-based registry of people with human immunodeficiency virus (HIV) infection to monitor the epidemic and inform resource allocation. We evaluated record linkages with the National Death Index (NDI) and the Social Security Administration's Death Master File (SSDMF) to find deaths occurring from 2000 through 2004. METHODS: We linked records from 32,837 people reported with HIV and not previously known to be dead with deaths reported in the NDI and the SSDMF. We calculated the kappa statistic to assess agreement between data sources. We performed subgroup analyses to assess differences within demographic and transmission risk subpopulations. We quantified the benefit of linkages with each data source beyond prior death ascertainment from local vital statistics data. RESULTS: We discovered 1,926 (5.87%) deaths, which reduced the HIV prevalence estimate in NYC by 2.03%, from 1.19% to 1.16%. Of these, 458 (23.78%) were identified only from NDI, and 305 (15.84%) only from SSDMF. Agreement in ascertainment between sources was substantial (kappa = [K] 0.74, 95% confidence interval [CI] 0.72, 0.76); agreement was lower among Hispanic people (K = 0.65, 95% CI 0.62, 0.69) and people born outside the U.S. (K = 0.60, 95% CI 0.52, 0.68). We identified an additional 13.62% of deaths to people reported with HIV in NYC; white people and men who have sex with men were disproportionately likely to be underascertained without these linkages (p < 0.0001). CONCLUSION: Record linkages with national databases are essential for accurate prevalence estimates from disease registries, and the SSDMF is an inexpensive means to supplement linkages with the NDI to maximize death ascertainment.

Human immunodeficiency virus partner elicitation and notification in new york city: public health does it better.

BACKGROUND: Partner notification (PN) is an effective strategy to identify undiagnosed human immunodeficiency virus (HIV) infections and to likely reduce HIV transmission. Whereas published literature has documented the benefits of provider referral for HIV PN, determination of the optimal provider--health department staff or community clinician--has not been previously studied. This study examined whether PN conducted by New York City (NYC) Disease Intervention Specialists (DIS) is more successful than PN conducted by community clinicians. METHODS: PN results overall and by index case-patient characteristics were compared for new HIV cases diagnosed in public sexually transmitted disease (STD) clinics versus those diagnosed in non-STD facilities. RESULTS: In NYC in 2004, 206 new HIV cases were diagnosed in STD clinics and 3460 in non-STD facilities. STD DIS personnel elicited 4 times as many partners per case diagnosed (0.87 vs. 0.22, P <0.01). Index case-patient characteristics differed between STD clinics and non-STD facilities, but STD DIS elicited more partners within all demographic and risk subgroups. Excluding partners previously HIV+, the proportion of partners notified was 70.9% for partners elicited by STD DIS and 48.3% for partners elicited by community clinicians (P <0.01). Among tested partners with previously unknown or negative status, the proportion of new HIV diagnoses was similar between those elicited by DIS and community clinicians (27.0% vs. 22.2%, P = 0.56). CONCLUSIONS: NYC STD DIS appear to be more effective than community clinicians at both partner elicitation and notification. NYC has stationed DIS at large healthcare facilities to assist community clinicians with the PN process.

Risk factors for delayed initiation of medical care after diagnosis of human immunodeficiency virus.

BACKGROUND: The full benefit of timely diagnosis of human immunodeficiency virus (HIV) infection is realized only if there is timely initiation of medical care. We used routine surveillance data to measure time to initiation of care in New York City residents diagnosed as having HIV by positive Western blot test in 2003. METHODS: The time between the first positive Western blot test and the first reported viral load and/or CD4 cell count or percentage was used to indicate the interval from initial diagnosis of HIV (non-AIDS) to first HIV-related medical care visit. Using Cox proportional hazards regression, we identified variables associated with delayed initiation of care and calculated their hazard ratios (HRs). RESULTS: Of 1928 patients, 1228 (63.7%) initiated care within 3 months of diagnosis, 369 (19.1%) initiated care later than 3 months, and 331 (17.2%) never initiated care. Predictors of delayed care were as follows: diagnosis at a community testing site (HR, 1.9; 95% confidence interval [CI], 1.5-2.3), the city correctional system (HR, 1.6; 95% CI, 1.2-2.0), or Department of Health sexually transmitted diseases or tuberculosis clinics (HR, 1.3; 95% CI, 1.1-1.6) vs a site with colocated primary medical care; nonwhite race/ethnicity (HR, 1.8; 95% CI, 1.5-2.0); injection drug use (HR, 1.3; 95% CI, 1.1-1.5); and location of birth outside the United States (HR, 1.1; 95% CI, 1.0-1.2). CONCLUSIONS: A total of 1597 persons (82.8%) diagnosed as having HIV in 2003 ever initiated care, most within 3 months of diagnosis. Initiation of care was most timely when diagnosis occurred at a testing site that offered colocated medical care. Improving referrals by nonmedical sites is critical. However, because most diagnoses occur in medical sites, improving linkage in these sites will have the greatest effect on timely initiation of care.

Concurrent HIV/AIDS diagnosis increases the risk of short-term HIV-related death among persons newly diagnosed with AIDS, 2002-2005.

Despite the overall effectiveness and availability of highly active antiretroviral therapy (HAART), 1500 HIV-related deaths still occur annually in New York City. In considering ways to further reduce deaths, we assessed the contribution of concurrent HIV/AIDS diagnosis to HIV-related mortality in New York City among persons newly diagnosed with AIDS. We used Cox regression to conduct a retrospective cohort analysis of HIV-related mortality among 15,211 residents age 13+ reported with AIDS to the population-based HIV/AIDS registry between January 2002 and June 2005. Concurrent HIV/AIDS diagnosis was defined as a diagnosis of AIDS occurring within 1 month of initial diagnosis of HIV. HIV-related mortality was 20.2% among persons diagnosed concurrently and 12.2% among those diagnosed nonconcurrently (p < 0.0001). Concurrent HIV/AIDS was associated with more than twice the risk of HIV-related death within the 4 months after diagnosis (hazard ratio [HR] 2.27, 95% confidence interval [CI] 1.94-2.65) but no increased risk thereafter (HR 1.12, 95% CI 0.77-1.61). Other significant predictors of death included injection drug use and birth in the Caribbean or Latin America. After 4 years 11.9% of all HIV-related deaths were attributable to a concurrent HIV/AIDS diagnosis. Public health initiatives that facilitate early diagnosis of HIV may reduce HIV-related mortality by giving people the opportunity to initiate care and begin treatment with HAART before immunosuppression places them at risk for opportunistic illness and death.

Causes of death among persons with AIDS in the era of highly active antiretroviral therapy: New York City.

BACKGROUND: Monitoring the full spectrum of causes of death among persons with AIDS is increasingly important as survival improves because of highly active antiretroviral therapy. OBJECTIVE: To describe recent trends in deaths due to HIV-related and non-HIV-related causes among persons with AIDS, identify factors associated with these deaths, and identify leading causes of non-HIV-related deaths. DESIGN: Population-based cohort analysis. SETTING: New York City. PATIENTS: All adults (age > or =13 years) living with AIDS between 1999 and 2004 who were reported to the New York City HIV/AIDS Reporting System and Vital Statistics Registry through 2004 (n = 68,669). MEASUREMENTS: Underlying cause of death on the death certificate. RESULTS: Between 1999 and 2004, the percentage of deaths due to non-HIV-related causes increased by 32.8% (from 19.8% to 26.3%; P = 0.015). The age-adjusted mortality rate decreased by 49.6 deaths per 10,000 persons with AIDS (P < 0.001) annually for HIV-related causes but only by 7.5 deaths per 10 000 persons with AIDS (P = 0.004) annually for non-HIV-related causes. Of deaths due to non-HIV-related causes, 76% could be attributed to substance abuse, cardiovascular disease, or a non-AIDS-defining type of cancer. Compared with men who have sex with men, injection drug users had a statistically significantly increased risk for death due to HIV-related causes (hazard ratio, 1.59 [95% CI, 1.49 to 1.70]) and non-HIV-related causes (hazard ratio, 2.54 [CI, 2.24 to 2.87]). LIMITATIONS: Compared with autopsy and chart review, death certificates may lack specificity in the underlying cause of death or detailed clinical and treatment-related information. CONCLUSIONS: Non-HIV-related causes of death account for one fourth of all deaths of persons with AIDS. Cardiovascular disease, non-AIDS-defining cancer, and substance abuse account for most non-HIV-related deaths. Reducing deaths from these causes requires a shift in the health care model for persons with AIDS from a primary focus on managing HIV infection to providing care that addresses all aspects of physical and mental health.

Tuberculosis prevention for non-US-born pregnant women.

OBJECTIVE: The purpose of this study was to evaluate whether non-US-born pregnant women receiving prenatal care are targeted for treatment of latent tuberculosis (TB) infection (LTBI) with isoniazid (INH) to prevent active TB. STUDY DESIGN: This was a retrospective chart review study of 730 non-US-born pregnant women receiving care at 5 New York City prenatal clinics from 1999 to 2000. RESULTS: Among 678 women with known tuberculin skin test (TST) status, 341 (50.3%) had a TST-positive result, including 200 who were newly diagnosed. Of 291 TST-positive women with no previous LTBI treatment or history of TB, 27 (9.3%) completed > or =6 months of INH. In a subset with detailed follow-up, the most important reasons for not completing treatment were nonreferral for evaluation of a TST-positive result (30.9%), not keeping the appointment (17.9%), and nonadherence with prescribed treatment (34.6%). CONCLUSION: The prenatal setting represents a missed opportunity to link TST-positive non-US-born women with LTBI treatment and support for treatment completion.