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Prueba de COVID-19 , COVID-19/diagnóstico , Procedimientos Quirúrgicos Electivos , Cuidados Preoperatorios , Infecciones Asintomáticas , COVID-19/epidemiología , COVID-19/transmisión , Humanos , Transmisión de Enfermedad Infecciosa de Paciente a Profesional/prevención & control , SARS-CoV-2 , Texas/epidemiología , Precauciones UniversalesRESUMEN
The PanNET Working Group of the 16th International Multiple Endocrine Neoplasia Workshop (MEN2019) convened in Houston, TX, USA, 27-29 March 2019 to discuss key unmet clinical needs related to PanNET in the context of MEN1, with a special focus on non-functioning (nf)-PanNETs. The participants represented a broad range of medical scientists as well as representatives from patient organizations, pharmaceutical industry and research societies. In a case-based approach, participants addressed early detection, surveillance, prognostic factors and management of localized and advanced disease. For each topic, after a review of current evidence, key unmet clinical needs and future research directives to make meaningful progress for MEN1 patients with nf-PanNETs were identified. International multi-institutional collaboration is needed for adequately sized studies and validation of findings in independent datasets. Collaboration between basic, translational and clinical scientists is paramount to establishing a translational science approach. In addition, bringing clinicians, scientists and patients together improves the prioritization of research goals, assures a patient-centered approach and maximizes patient involvement. It was concluded that collaboration, research infrastructure, methodologic and reporting rigor are essential to any translational science effort. The highest priority for nf-PanNETs in MEN1 syndrome are (1) the development of a data and biospecimen collection architecture that is uniform across all MEN1 centers, (2) unified strategies for diagnosis and follow-up of incident and prevalent nf-PanNETs, (3) non-invasive detection of individual nf-PanNETs that have an increased risk of metastasis, (4) chemoprevention clinical trials driven by basic research studies and (5) therapeutic targets for advanced disease based on biologically plausible mechanisms.
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Neoplasia Endocrina Múltiple Tipo 1/complicaciones , Neoplasias Pancreáticas/etiología , Adulto , Femenino , Humanos , Neoplasias Pancreáticas/patologíaRESUMEN
Pancreatic cancer is a challenging malignancy to treat, largely due to aggressive regional involvement, early systemic dissemination, high recurrence rate, and subsequent low patient survival. Generally, 15-20% of newly diagnosed pancreatic cancers are candidates for possible curative resection. Eighty percent of these patients, however, will experience locoregional or distant recurrence in first 2 years. Although there is no strong evidence-based guideline for optimal surveillance after pancreatic cancer resection, careful comparison of surveillance follow-up multi-detector CT (MDCT) studies with a postoperative baseline MDCT examination aids detection of early recurrent pancreatic cancer. In this review article, we describe imaging findings suggestive of recurrent pancreatic cancer and review routine and alternative imaging options.
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Recurrencia Local de Neoplasia/diagnóstico por imagen , Recurrencia Local de Neoplasia/patología , Pancreatectomía , Neoplasias Pancreáticas/diagnóstico por imagen , Neoplasias Pancreáticas/patología , Neoplasias Pancreáticas/cirugía , Tomografía Computarizada por Rayos X/métodos , Humanos , Vigilancia de la Población , Complicaciones Posoperatorias/diagnóstico por imagenRESUMEN
BACKGROUND: Pancreatic ductal adenocarcinoma has a poor prognosis without surgery. No standard treatment has yet been accepted for patients with portal-superior mesenteric vein (PV-SMV) infiltration. The present meta-analysis aimed to compare the results of pancreatic resection with PV-SMV resection for suspected infiltration with the results of surgery without PV-SMV resection. METHODS: A systematic search was performed of PubMed, Embase and the Cochrane Library in accordance with PRISMA guidelines from the time of inception to 2013. The inclusion criteria were comparative studies including patients who underwent pancreatic resection with or without PV-SMV resection. One, 3- and 5-year survival were the primary outcomes. RESULTS: Twenty-seven studies were identified involving a total of 9005 patients (1587 in PV-SMV resection group). Patients undergoing PV-SMV resection had an increased risk of postoperative mortality (risk difference (RD) 0.01, 95 per cent c.i. 0.00 to 0.03; P = 0.2) and of R1/R2 resection (RD 0.09, 0.06 to 0.13; P < 0.001) compared with those undergoing standard surgery. One-, 3- and 5-year survival were worse in the PV-SMV resection group: hazard ratio 1.23 (95 per cent c.i. 1.07 to 1.43; P = 0.005), 1.48 (1.14 to 1.91; P = 0.004) and 3.18 (1.95 to 5.19; P < 0.001) respectively. Median overall survival was 14.3 months for patients undergoing pancreatic resection with PV-SMV resection and 19.5 months for those without vein resection (P = 0.063). Neoadjuvant therapies recently showed promising results. CONCLUSION: This meta-analysis showed increased postoperative mortality, higher rates of non-radical surgery and worse survival after pancreatic resection with PV-SMV resection. This may be related to more advanced disease in this group.
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Carcinoma Ductal Pancreático/cirugía , Venas Mesentéricas/cirugía , Neoplasias Pancreáticas/cirugía , Pancreaticoduodenectomía/métodos , Vena Porta/cirugía , Humanos , Resultado del TratamientoRESUMEN
Precise fluorescence-guided surgery (FGS) for pancreatic cancer has the potential to greatly improve the outcome in this recalcitrant disease. To achieve this goal, we have used genetic reporters to color code cancer and stroma cells in a patient-derived orthotopic xenograft (PDOX) model. The telomerase-dependent green fluorescent protein (GFP)-containing adenovirus OBP-401 was used to label the cancer cells of a pancreatic cancer PDOX. The PDOX was previously grown in a red fluorescent protein (RFP) transgenic mouse that stably labeled the PDOX stroma cells bright red. The color-coded PDOX model enabled FGS to completely resect the pancreatic tumors including stroma. Dual-colored FGS significantly prevented local recurrence, which bright-light surgery or single-color FGS could not. FGS, with color-coded cancer and stroma cells has important potential for improving the outcome of recalcitrant-cancer surgery.
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Recurrencia Local de Neoplasia/prevención & control , Neoplasias Pancreáticas/cirugía , Cirugía Asistida por Computador , Animales , Genes Reporteros , Proteínas Fluorescentes Verdes/biosíntesis , Proteínas Fluorescentes Verdes/genética , Proteínas Luminiscentes/biosíntesis , Proteínas Luminiscentes/genética , Ratones Desnudos , Ratones Transgénicos , Trasplante de Neoplasias , Neoplasias Pancreáticas/metabolismo , Neoplasias Pancreáticas/patología , Proteína Fluorescente RojaRESUMEN
OBJECTIVES: To evaluate trends in the HIV epidemic among men who have sex with men (MSM) in San Francisco and the implications for HIV prevention. METHODS: An ecological approach assessed temporal trends in sexual risk behaviour, sexually transmitted infections (STI), HIV incidence and prevalence from multiple data sources between 1998 and 2007. RESULTS: By 2007, there were over 13 000 HIV-infected MSM living in San Francisco. No consistent upward or downward temporal trends were found in HIV incidence, newly reported HIV cases, AIDS deaths, proportion of AIDS cases using antiretroviral therapy, rectal gonorrhoea or primary and secondary syphilis cases among MSM during the study period. Trends in indicators of sexual risk behaviour among MSM were mixed. Overall, unprotected anal intercourse (UAI) increased in community-based surveys. Among HIV-positive MSM, no significant trends were noted for UAI. Among HIV-negative MSM, UAI with unknown serostatus partners decreased but increased with potentially discordant serostatus partners. Among MSM seeking HIV testing, increases were noted in insertive UAI at anonymous testing sites and at the STI clinic, in receptive UAI at anonymous test sites and in receptive UAI with a known HIV-positive partner at the STI clinic. CONCLUSIONS: Temporal trends in multiple biological and behavioural indicators over the past decade describe a hyperendemic state of HIV infection among MSM in San Francisco, whereby prevalence has stabilised at a very high level. In the absence of new, effective prevention strategies this state will persist.
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Homosexualidad Masculina/estadística & datos numéricos , Enfermedades de Transmisión Sexual/epidemiología , Sexo Inseguro/estadística & datos numéricos , Enfermedades Endémicas , Infecciones por VIH/epidemiología , Infecciones por VIH/psicología , Seroprevalencia de VIH/tendencias , Humanos , Incidencia , Masculino , Prevalencia , San Francisco/epidemiología , Enfermedades de Transmisión Sexual/psicologíaRESUMEN
BACKGROUND: Sexually transmitted infections (STI) and unprotected anal intercourse (UAI) have been increasing among men who have sex with men (MSM) in San Francisco. However, HIV incidence has stabilised. OBJECTIVES: To describe recent trends in sexual risk behaviour, STI, and HIV incidence among MSM in San Francisco and to assess whether increases in HIV serosorting (that is, selective unprotected sex with partners of the same HIV status) may contribute to preventing further expansion of the epidemic. METHODS: The study applies an ecological approach and follows the principles of second generation HIV surveillance. Temporal trends in biological and behavioural measures among MSM were assessed using multiple pre-existing DATA SOURCES: STI case reporting, prevention outreach programmatic data, and voluntary HIV counselling and testing data. RESULTS: Reported STI cases among MSM rose from 1998 through 2004, although the rate of increase slowed between 2002 and 2004. Rectal gonorrhoea cases increased from 157 to 389 while early syphilis increased from nine to 492. UAI increased overall from 1998 to 2004 (p<0.001) in community based surveys; however, UAI with partners of unknown HIV serostatus decreased overall (p<0.001) among HIV negative MSM, and among HIV positive MSM it declined from 30.7% in 2001 to a low of 21.0% in 2004 (p<0.001). Any UAI, receptive UAI, and insertive UAI with a known HIV positive partner decreased overall from 1998 to 2004 (p<0.001) among MSM seeking anonymous HIV testing and at the STI clinic testing programme. HIV incidence using the serological testing algorithm for recent HIV seroconversion (STARHS) peaked in 1999 at 4.1% at the anonymous testing sites and 4.8% at the STI clinic voluntary testing programme, with rates levelling off through 2004. CONCLUSIONS: HIV incidence among MSM appears to have stabilised at a plateau following several years of resurgence. Increases in the selection of sexual partners of concordant HIV serostatus may be contributing to the stabilisation of the epidemic. However, current incidence rates of STI and HIV remain high. Moreover, a strategy of risk reduction by HIV serosorting can be severely limited by imperfect knowledge of one's own and one's partners' serostatus.
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Homosexualidad Masculina/estadística & datos numéricos , Enfermedades de Transmisión Sexual/epidemiología , Adulto , Femenino , Infecciones por VIH/diagnóstico , Infecciones por VIH/epidemiología , Seropositividad para VIH , Humanos , Incidencia , Masculino , Persona de Mediana Edad , Prevalencia , Factores de Riesgo , San Francisco/epidemiología , Parejas Sexuales , Sexo InseguroRESUMEN
BACKGROUND: Despite intensive research, the main causes of postoperative nausea and vomiting (PONV) remain unclear. We sought to quantify the relative importance of operative, anaesthetic and patient-specific risk factors to the development of PONV. METHODS: We conducted a randomized controlled trial of 1180 children and adults at high risk for PONV scheduled for elective surgery. Using a five-way factorial design, we randomly assigned subjects by gender who were undergoing specific operative procedures, to receive various combinations of anaesthetics, opioids, and prophylactic antiemetics. RESULTS: Of the 1180 patients, 355 (30.1% 95% CI (27.5-32.7%)) had at least one episode of postoperative vomiting (PV) within 24 h post-anaesthesia. In the early postoperative period (0-2 h), the leading risk factor for vomiting was the use of volatile anaesthetics, with similar odds ratios (OR (95% CI)) being found for isoflurane (19.8 (7.7-51.2)), enflurane (16.1 (6.2-41.8)) and sevoflurane (14.5 (5.6-37.4)). A dose-response relationship was present for the use of volatile anaesthetics. In contrast, no dose response existed for propofol anaesthesia. In the delayed postoperative period (2-24 h), the main predictors were being a child (5.7 (3.0-10.9)), PONV in the early period (3.4 (2.4-4.7)) and the use of postoperative opioids (2.5 (1.7-3.7)). The influence of the antiemetics was considerably smaller and did not interact with anaesthetic or surgical variables. CONCLUSION: Volatile anaesthetics were the leading cause of early postoperative vomiting. The pro-emetic effect was larger than other risk factors. In patients at high risk for PONV, it would therefore make better sense to avoid inhalational anaesthesia rather than simply to add an antiemetic, which may still be needed to prevent or treat delayed vomiting.
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Anestésicos por Inhalación/efectos adversos , Náusea y Vómito Posoperatorios/inducido químicamente , Adolescente , Adulto , Anestésicos por Inhalación/administración & dosificación , Niño , Preescolar , Relación Dosis-Respuesta a Droga , Método Doble Ciego , Esquema de Medicación , Femenino , Humanos , Modelos Logísticos , Masculino , Persona de Mediana Edad , Oportunidad Relativa , Periodo Posoperatorio , Factores de RiesgoRESUMEN
In a nonrandomized study of nonoccupational postexposure prophylaxis (PEP), a cross-sectional evaluation of subjects who were the source of human immunodeficiency (HIV) exposure was performed to characterize partners of index subjects seeking nonoccupational PEP against HIV. Among 401 index subjects, 64 (16%) recruited a source subject. Those in a steady relationship and those who knew that the source subject was HIV antibody positive were more likely to recruit their source subject. Source subjects reported high rates of past (78%) and current (69%) antiretroviral use; 46% of those using antiretroviral drugs had detectable plasma HIV-1 RNA levels. Antiretroviral resistance was detected in many source subjects who reported any use of antiretrovirals and was rare among source subjects who reported no history of antiretroviral use. Clinicians often make treatment decisions on the basis of incomplete knowledge of the source subject's HIV status or antiretroviral treatment history. The treatment history, particularly nonuse of a class of antiretroviral drugs, can be used to predict drug resistance.
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Fármacos Anti-VIH/uso terapéutico , Trazado de Contacto , Infecciones por VIH/tratamiento farmacológico , Infecciones por VIH/prevención & control , Conducta Sexual , Abuso de Sustancias por Vía Intravenosa , Adulto , Fármacos Anti-VIH/farmacología , Estudios Transversales , Farmacorresistencia Viral/genética , Femenino , Anticuerpos Anti-VIH/sangre , Infecciones por VIH/transmisión , VIH-1/genética , VIH-1/inmunología , Humanos , Masculino , ARN Viral/sangreRESUMEN
Highly active antiretroviral therapy (HAART) has contributed to a decrease in AIDS-related morbidity and mortality. This study used population-based AIDS surveillance data to evaluate the prevalence and predictors of HAART use among persons with AIDS in San Francisco. Use of HAART among persons living with AIDS increased from 41% in 1996 to 72% in 1999. Fourteen percent of persons diagnosed with AIDS between 1996 and 1999 initiated HAART before their AIDS diagnosis. Use of HAART before an AIDS diagnosis increased from 5% in 1996 to 26% in 1999. In the multivariable analysis, African Americans, injection drug users, and those without insurance at the time of AIDS diagnosis were less likely to use HAART before AIDS diagnosis. Delayed initiation of HAART after AIDS was more likely to occur among African Americans, injection drug users, homeless persons, those with public insurance, and those with higher CD4 counts. Although the overall prevalence of HAART use was high, disparity in use of HAART existed by race and risk group, patient's insurance status, and facility of diagnosis. Barriers in use of treatment should be identified so all persons with AIDS can benefit from improved therapies.
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Síndrome de Inmunodeficiencia Adquirida/tratamiento farmacológico , Fármacos Anti-VIH/uso terapéutico , Síndrome de Inmunodeficiencia Adquirida/epidemiología , Adolescente , Adulto , Terapia Antirretroviral Altamente Activa , Estudios de Cohortes , Femenino , Humanos , Masculino , Persona de Mediana Edad , Análisis Multivariante , Vigilancia de la Población , San Francisco/epidemiologíaRESUMEN
OBJECTIVE: To estimate HIV incidence among male-to-female transgendered persons (MtF transgendered persons) who repeatedly tested for HIV antibodies at public San Francisco counseling and testing sites between July 1997 and June 2000. METHODS: HIV seroconversions were identified and person-time of observation were estimated using the date and result of the current test and the self-reported date and result of the previous test. Factors independently associated with HIV seroconversion were determined using multivariable proportional hazard analysis. RESULTS: HIV incidence was 7.8 per 100 person-years (95% confidence intervals [CI], 4.6-12.3) based on 13 seroconversions among 155 repeat testers with 167.7 person-years of observation. African-American race/ethnicity (adjusted relative hazard ratio [HR], 5.0; 95% CI, 1.5-16.2) and unprotected receptive anal intercourse (HR, 3.9; 95% CI, 1.2-13.1) were independent predictors of HIV seroconversion. CONCLUSIONS: HIV is currently spreading at an extremely high rate among MtF transgendered persons in San Francisco, especially those who are African Americans.
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Infecciones por VIH/epidemiología , Transexualidad , Adulto , Anciano , Estudios de Cohortes , Femenino , Anticuerpos Anti-VIH/sangre , Infecciones por VIH/sangre , Infecciones por VIH/virología , Humanos , Incidencia , Masculino , Persona de Mediana Edad , Análisis Multivariante , San Francisco/epidemiologíaRESUMEN
OBJECTIVES: To estimate HIV incidence, characterize correlates of HIV seroconversion, and monitor temporal trends in HIV transmission among patients repeatedly tested for HIV by a county hospital in San Francisco. DESIGN: Retrospective longitudinal study. METHODS: HIV incidence was retrospectively calculated among persons voluntarily tested for HIV antibody more than once at San Francisco's county hospital or one of its affiliated satellite community clinics between 1993 and 1999. Linkage of HIV test results in computerized databases identified "seroconverters" as individuals who had a negative antibody test followed by a positive test. The interval between tests was used as the person-time at risk. Cox proportional hazards analysis identified correlates of HIV seroconversion. RESULTS: A total of 84 HIV seroconversions were identified among 2893 eligible patients repeatedly tested for HIV antibody over a cumulative 5860 person-years (PYs) (incidence of 1.4 per 100 PYs, 95% confidence interval [CI]: 1.2-1.7). The majority of seroconversions (71 [84.5%]) were among injection drug users (IDUs) (incidence of 2.0 per 100 PYs, CI: 1.6-2.4). HIV incidence was highest among men who have sex with men (MSM) who were also IDUs (incidence of 3.8 per 100 PYs, CI: 2.7-5.1) and lowest among non-IDUs, heterosexual men, and non-IDU women (incidence of 0.3 per 100 PYs, CI: 0.1-0.6). In multivariate analysis, correlates of HIV seroconversion were age 25 to 29 years (hazard ratio [HR] = 3.9, CI: 2.4-6.3), MSM (HR = 2.9, CI: 1.9-4.4), and IDU (HR = 3.2, CI: 1.8-5.8). Overall, no temporal trend in annual HIV incidence was noted during the study period; however, HIV incidence among MSM IDUs increased from 2.9 per 100 PYs in 1996 to 4.7 per 100 PYs in 1998. CONCLUSIONS: The rate of seroconversion in this hospital and affiliated clinic population is unexpectedly high. Moreover, HIV transmission among IDU patients has not decreased over the last several years. The San Francisco county hospital provides a high-risk sentinel population to monitor emerging trends in HIV transmission, especially among IDUs, and presents multiple opportunities for prevention interventions, because these patients are being seen repeatedly by clinicians.
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Serodiagnóstico del SIDA , Infecciones por VIH/epidemiología , Ensayo de Inmunoadsorción Enzimática , Infecciones por VIH/diagnóstico , Infecciones por VIH/transmisión , Hospitales de Condado , Humanos , Incidencia , Modelos de Riesgos Proporcionales , San Francisco/epidemiologíaRESUMEN
BACKGROUND: Although case management has been advocated as a method for improving the care of chronically ill persons, its effectiveness is poorly understood. OBJECTIVE: To assess the effect of case managers on unmet need for supportive services and utilization of medical care and medications among HIV-infected persons. DESIGN: Baseline and follow-up interview of a national probability sample. SETTING: Inpatient and outpatient medical facilities in the United States. PARTICIPANTS: 2437 HIV-infected adults representing 217 081 patients receiving medical care. MEASUREMENTS: Outcomes measured at follow-up were unmet need for supportive services, medical care utilization (ambulatory visits, emergency department visits, and hospitalizations), and use of HIV medication (receipt of antiretroviral therapy and prophylaxis against Pneumocystis carinii pneumonia and toxoplasmosis). RESULTS: At baseline, 56.5% of the sample had contact with a case manager in the previous 6 months. In multiple logistic regression analyses that adjusted for potential confounders, contact with a case manager at baseline was associated with decreased unmet need for income assistance (odds ratio [OR], 0.57 [95% CI, 0.36 to 0.91]), health insurance (OR, 0.54 [CI, 0.33 to 0.89]), home health care (OR, 0.29 [CI, 0.15 to 0.56]), and emotional counseling (OR, 0.62 [CI, 0.41 to 0.94]) at follow-up. Contact with case managers was not significantly associated with utilization of ambulatory care (OR, 0.77 [CI, 0.57 to 1.04]), hospitalization (OR, 1.13 [CI, 0.84 to 1.54]), or emergency department visits (OR, 1.30 [CI, 0.97 to 1.73]) but was associated with higher utilization of two-drug (OR, 1.58 [CI, 1.23 to 2.03]) and three-drug (OR, 1.34 [CI, 1.00 to 1.80]) antiretroviral regimens and of treatment with protease inhibitors or non-nucleoside reverse transcriptase inhibitors (OR, 1.29 [CI, 1.02 to 1.64]) at follow-up. CONCLUSIONS: Case management appears to be associated with fewer unmet needs and higher use of HIV medications in patients receiving HIV treatment.
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Fármacos Anti-VIH/uso terapéutico , Manejo de Caso , Infecciones por VIH/tratamiento farmacológico , Necesidades y Demandas de Servicios de Salud , Servicios de Salud/estadística & datos numéricos , Adulto , Factores de Confusión Epidemiológicos , Femenino , Humanos , Entrevistas como Asunto , Masculino , Análisis de Regresión , Estados UnidosRESUMEN
We retrospectively assessed the cost-effectiveness of providing prevention referrals to high-risk seronegatives at HIV test sites in San Francisco. We examined the costs and effects from the perspectives of society and the San Francisco Department of Public Health (SFDPH). Cost categories assessed included referral materials, counsellor training and time required to make referrals, prevention services and the value of client time. Effect data are drawn from a study of 289 high-risk seronegatives and the published literature, and are applied to a city-wide caseload of 6,626 high-risk seronegatives. We estimate that a city-wide programme in San Francisco averts two HIV infections per year and yields net savings to society of $43,765, with a cost to the SFDPH of $20,738 per HIV infection averted. We conclude that providing HIV prevention referrals to high-risk seronegatives receiving antibody testing imposes significant costs, but has attractive cost-effectiveness when applied to a large high-risk population.
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Infecciones por VIH/economía , Servicios Preventivos de Salud/economía , Derivación y Consulta/economía , Adulto , Análisis Costo-Beneficio , Infecciones por VIH/epidemiología , Infecciones por VIH/prevención & control , Seronegatividad para VIH , Humanos , Incidencia , Masculino , Compartición de Agujas , Estudios Retrospectivos , Asunción de Riesgos , San Francisco/epidemiología , Conducta Sexual , Servicios Urbanos de Salud/economíaRESUMEN
OBJECTIVES: This study determined infection risk for HIV, hepatitis B virus (HBV), and hepatitis C virus (HCV) from needle reuse at a phlebotomy center that possibly exposed 3810 patients to infection. METHODS: We used a model for the risk of infection per blood draw, supplemented by subsequent testing results from 1699 patients. RESULTS: The highest risk of transmission was for HBV infection: 1.1 x 10(-6) in the best case and 1.2 x 10(-3) in the (unlikely) worst case. Subsequent testing yielded prevalence rates of 0.12%, 0.41%, and 0.88% for HIV, HBV, and HCV, respectively, lower than National Health and Nutrition Examination Survey III prevalence estimates. CONCLUSIONS: The infection risk was very low; few, if any, transmissions are likely to have occurred.
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Equipo Reutilizado , Infecciones por VIH/transmisión , Hepatitis B/transmisión , Hepatitis C/transmisión , Control de Infecciones/métodos , Agujas/virología , Flebotomía/instrumentación , California , Contaminación de Equipos , Humanos , Flebotomía/normas , Probabilidad , Medición de Riesgo/estadística & datos numéricosRESUMEN
To determine why HIV-infected persons do not access needed services, we interviewed clients of Ryan White CARE-funded agencies in San Francisco, San Mateo and Marin Counties. From July to September 1996, we interviewed 519 clients receiving services at 65 CARE-funded sites. Just over half the clients (54.5%) had at least one unmet service need in the previous four months; persons in an unstable living situation and those with lower perceived health status were significantly more likely to have an unmet need. For persons with unmet needs, agency barriers were most common (54.0%), followed by emotional issues (44.8%), lack of information (44.0%) and financial/practical barriers (19.4%). None of the client characteristics (sex, race/ethnicity, age, living situation, perceived health status and risk group) were consistently or significantly (p < 0.05) associated with specific barriers. We believe that the similarity between clients with and without unmet needs reflects the success of CARE in eliminating many barriers. However, the persistence of certain barriers and lack of sub-group-specific barriers suggests the need for individualized interventions to improve service delivery, publicize service availability and address the emotional barriers to accessing HIV-related care.
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Atención a la Salud , Infecciones por VIH/psicología , Aceptación de la Atención de Salud , Adulto , Anciano , Distribución de Chi-Cuadrado , Barreras de Comunicación , Femenino , Estado de Salud , Humanos , Estilo de Vida , Masculino , Persona de Mediana Edad , Satisfacción del Paciente , Apoyo SocialRESUMEN
BACKGROUND: There has been an increase in high-risk sexual behaviour and sexually transmitted diseases (STD) during the time period when highly active antiretroviral therapy (HAART) became widely available. We examined whether taking HAART increased the risk of acquiring an STD--an epidemiological marker of unsafe sex--in people with AIDS. METHODS: We did a computerised match of people in the San Francisco STD and AIDS registries. People with AIDS who were diagnosed before 1999 and alive in November, 1995, or later, were classified as having had an STD after AIDS diagnosis or not having had an STD after AIDS diagnosis. We used a Cox proportional hazards model to see whether use of antiretroviral therapy was associated with acquiring an STD after AIDS, after adjustment for sex, age, race, HIV-1 risk category, and CD4 count at AIDS diagnosis. FINDINGS: People with AIDS who had had HAART showed an independent increase in the risk of developing an STD (hazard ratio 4.10; 95% CI 2.84-5.94). Americans of African origin, younger age, and higher CD4 count at AIDS diagnosis were also associated with acquiring an STD after AIDS. The number of people living with AIDS who acquired an STD increased over time from 60 (0.66%) in 1995 to 113 (1.32%) in 1998 (p<0.001). INTERPRETATION: We have shown that people on HAART are more likely to develop an STD, an epidemiological marker of unsafe sex. More intensive risk-reduction counselling and STD screening for people with AIDS is needed.
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Infecciones Oportunistas Relacionadas con el SIDA/diagnóstico , Síndrome de Inmunodeficiencia Adquirida/tratamiento farmacológico , Terapia Antirretroviral Altamente Activa , VIH-1 , Enfermedades Bacterianas de Transmisión Sexual/diagnóstico , Infecciones Oportunistas Relacionadas con el SIDA/transmisión , Adolescente , Adulto , Recuento de Linfocito CD4 , Femenino , VIH-1/efectos de los fármacos , Conocimientos, Actitudes y Práctica en Salud , Homosexualidad Masculina/estadística & datos numéricos , Humanos , Masculino , Persona de Mediana Edad , Vigilancia de la Población , Riesgo , Sexo Seguro , San Francisco , Enfermedades Bacterianas de Transmisión Sexual/transmisiónRESUMEN
The feasibility of providing postexposure prophylaxis (PEP) after sexual or injection drug use exposures to human immunodeficiency virus (HIV) was evaluated. PEP was provided within 72 h to individuals with exposures from partners known to have or to be at risk for HIV infection. PEP consisted of 4 weeks of antiretroviral medications and individually tailored risk-reduction and medication-adherence counseling. Among 401 participants seeking PEP, sexual exposures were most common (94%; n=375). Among sexual exposures, receptive (40%) and insertive (27%) anal intercourse were the most common sexual acts. The median time from exposure to treatment was 33 h. Ninety-seven percent of participants were treated exclusively with dual reverse-transcriptase inhibitors, and 78% completed the 4-week treatment. Six months after the exposure, no participant developed HIV antibodies, although a second PEP course for a subsequent exposure was provided to 12%. PEP, after nonoccupational HIV exposure, is feasible for persons at risk for HIV infection.
Asunto(s)
Fármacos Anti-VIH/uso terapéutico , Infecciones por VIH/prevención & control , Inhibidores de la Transcriptasa Inversa/uso terapéutico , Enfermedades Virales de Transmisión Sexual/prevención & control , Abuso de Sustancias por Vía Intravenosa/complicaciones , Adolescente , Adulto , Anciano , Trazado de Contacto , Consejo , Didanosina/uso terapéutico , Femenino , Infecciones por VIH/tratamiento farmacológico , Humanos , Lamivudine/uso terapéutico , Masculino , Persona de Mediana Edad , Nelfinavir/uso terapéutico , Cooperación del Paciente , Factores de Riesgo , Asunción de Riesgos , Enfermedades Virales de Transmisión Sexual/tratamiento farmacológico , Factores de Tiempo , Zidovudina/uso terapéuticoRESUMEN
OBJECTIVES: To field-test the availability, interpretability, and programmatic usefulness of 37 proposed national HIV prevention indicators (HPI) intended to evaluate community-level impact of HIV prevention efforts in San Francisco. METHODS: HPI were defined for four populations (high risk heterosexuals, injecting drug users, men who have sex with men, and childbearing women) and for four domains (biological, behavioral, service, and socio-political). HPI were obtained from existing data sources only. Trends in HPI were examined from 1990 to 1997. RESULTS: Existing data provided 29 (78%) of the 37 proposed HPI; eight HPI were not available because California does not have HIV case reporting. Interpretation was limited for several HPI due to small sample size, inconsistencies in data collection, or lack of contextual information. Data providing behavioral HPI were scarce. HPI were consistent with historical patterns of HIV transmission in San Francisco but also highlighted new and worrisome trends. Notably, HPI identified recent increases in risk for HIV transmission among men who have sex with men. CONCLUSIONS: Despite limitations, the proposed national HPI provided evidence of the aggregate effectiveness of prevention efforts in San Francisco. Supplemental or local HPI are needed to fill data gaps, add context, and increase the scope and programmatic usefulness of the national HPI.