Lower Gastrointestinal Kaposi Sarcoma in HIV/AIDS: A Diagnostic Challenge.

Gastrointestinal Kaposi sarcoma (GI-KS) is the most common extra-cutaneous site of KS in HIV/AIDS, and the majority (75%) of affected patients are asymptomatic. GI-KS rarely occurs in the absence of cutaneous lesions. Opportunistic GI infections in HIV/AIDS and GI-KS can present with similar symptoms especially diarrhea, creating a diagnostic challenge. We present a 46-year-old homosexual male with a medical history of HIV/AIDS and neurosyphilis, who presented with 2 weeks of nonbloody diarrhea and abdominal discomfort. He was initially worked up for infectious diarrhea, initiated on highly active anti-retroviral (HAART) and supportively managed with rehydration therapy and analgesia. However, his clinical symptoms did not improve, necessitating abdomen/pelvic CT scan which revealed extensive recto-sigmoid colon thickening and pelvic lymphadenopathy. Due to a high suspicion of malignancy, diagnostic endoscopy and biopsy were done which showed colonic KS. He was treated with intravenous pegylated doxorubicin in addition to HAART which evidently resulted in significant clinical and radiological improvement. The diagnosis of GI-KS could be challenging in the presence of overlapping features with opportunistic GI infections and the absence of cutaneous manifestations of KS because clinicians tend to focus more on infectious etiology. We suggest that clinicians should consider GI-KS in the differential diagnosis of patients with HIV/AIDS that present with diarrhea and other nonspecific abdominal symptoms. Early endoscopic evaluation with biopsy could help to ensure the timely diagnosis and management of GI-KS and ultimately improve outcomes.

A Quality Improvement Project to Increase Early Detection of Syphilis Infection or Re-infection in HIV-infected Men Who Have Sex With Men.

Our quality improvement project evaluated whether testing for syphilis every 3 to 6 months with routine HIV laboratory monitoring had an effect on early detection of asymptomatic syphilis infection/re-infection in HIV-infected men who have sex with men. Retrospective analysis of syphilis testing and infections in a sample of this population (N = 245) was conducted after establishing a change-of-practice quality improvement initiative in a not-for-profit, community-based, grant-funded clinic. We compared the clinic's annual rates of syphilis before and after intervention implementation. The detection rate was 6.6% in the preintervention practice change group and 15.5% in the postintervention group. Increased testing identified 27 syphilis cases that would not otherwise have been identified until the annual comprehensive examination. Increased testing frequency led to earlier detection of syphilis, which was clinically significant, showing a potential to decrease the number of new syphilis and HIV infections and to decrease health care expenditures.

Adherence to highly active antiretroviral therapy impact on clinical and economic outcomes for Medicaid enrollees with human immunodeficiency virus and hepatitis C coinfection.

We examined the impact of antiretroviral treatment adherence among hepatitis C (HCV) coinfected human immunodeficiency virus (HIV) patients on survival and clinical outcomes. We analyzed Medicaid claims data from 14 southern states from 2005 to 2007, comparing survival and clinical outcomes and cost of treatment for HIV and HCV coinfected patients (N = 4115) at different levels of adherence to antiretroviral therapy (ART). More than one in five patients (20.5%) showed less than 50% adherence to antiretroviral treatment, but there were no racial/ethnic or gender disparities. Significant survival benefit was demonstrated at each incremental level of adherence to ART (one-year mortality ranging from 3.5% in the highest adherence group to 26.0% in the lowest). Low-adherence patients also had higher rates of hospitalization and emergency department visits. Relative to patients with high (>95%) ART adherence, those with less than 25% treatment adherence had fourfold greater risk of death (adjusted odds ratio 4.22 [95% CI: 3.03, 5.87]). Nondrug Medicaid expenditures were lower for high-adherence patients, but cost of medications drove total Medicaid expenditures higher for high-adherence patients. Cost per quality-adjusted life year (QALY) saved (relative to the <25% low-adherence group) ranged from $21,874 for increasing adherence to 25-50% to $37,229 for increasing adherence to 75-95%. Adherence to ART for patients with HIV and HCV coinfection is associated with lower adverse clinical outcomes at a Medicaid cost per QALY commensurate with other well-accepted treatment and prevention strategies. Further research is needed to identify interventions which can best achieve optimal ART adherence at a population scale.

The potential for elimination of racial-ethnic disparities in HIV treatment initiation in the Medicaid population among 14 southern states.

OBJECTIVES: The purpose of this study was to explore the racial and ethnic disparities in initiation of antiretroviral treatment (ARV treatment or ART) among HIV-infected Medicaid enrollees 18-64 years of age in 14 southern states which have high prevalence of HIV/AIDS and high racial disparities in HIV treatment access and mortality. METHODS: We used Medicaid claims data from 2005 to 2007 for a retrospective cohort study. We compared frequency variances of HIV treatment uptake among persons of different racial- ethnic groups using univariate and multivariate methods. The unadjusted odds ratio was estimated through multinomial logistic regression. The multinomial logistic regression model was repeated with adjustment for multiple covariates. RESULTS: Of the 23,801 Medicaid enrollees who met criteria for initiation of ARV treatment, only one third (34.6%) received ART consistent with national guideline treatment protocols, and 21.5% received some ARV medication, but with sub-optimal treatment profiles. There was no significant difference in the proportion of people who received ARV treatment between black (35.8%) and non-Hispanic whites (35.7%), but Hispanic/Latino persons (26%) were significantly less likely to receive ARV treatment. CONCLUSIONS: Overall ARV treatment levels for all segments of the population are less than optimal. Among the Medicaid population there are no racial HIV treatment disparities between Black and White persons living with HIV, which suggests the potential relevance of Medicaid to currently uninsured populations, and the potential to achieve similar levels of equality within Medicaid for Hispanic/Latino enrollees and other segments of the Medicaid population.

The influence of sex, race/ethnicity, and educational attainment on human immunodeficiency virus death rates among adults, 1993-2007.

BACKGROUND: Overall declines in human immunodeficiency virus (HIV) mortality may mask patterns for subgroups, and prior studies of disparities in mortality have used area-level vs individual-level socioeconomic status measures. The aim of this study was to examine temporal trends in HIV mortality by sex, race/ethnicity, and individual level of education (as a proxy for socioeconomic status). METHODS: We examined HIV deaths among non-Hispanic white, non-Hispanic black, and Hispanic men and women aged 25 to 64 years in 26 states (1993-2007; N=91 307) reported to the National Vital Statistics System. The main outcome measures were age-standardized HIV death rates, rate differences, and rate ratios by educational attainment and between the least- and the most-educated (≤12 vs ≥16 years) individuals. RESULTS: Between 1993-1995 and 2005-2007, mortality declined for most men and women by race/ethnicity and educational levels, with the greatest absolute decreases for nonwhites owing to their higher baseline rates. Among men with the most education, rates per 100 000 population decreased from 117.89 (95% CI, 101.08-134.70) to 15.35 (12.08-18.62) in blacks vs from 26.42 (24.93-27.92) to 1.79 (1.50-2.08) in whites. Rates were unchanged for the least-educated black women (26.76; 95% CI, 24.30-29.23; during 2005-2007) and remained high for similarly educated black men (52.71; 48.96-56.45). Relative declines were greater with increasing levels of education (P < .001), resulting in widening disparities. Among men, the disparity rate ratio (comparing the least and the most educated) increased from 1.04 (95% CI, 0.89-1.21) during 1993-1995 to 3.43 (2.74-4.30) during 2005-2007 for blacks and from 0.98 (0.91-1.05) to 2.82 (2.34-3.40) for whites. CONCLUSION: Although absolute declines in HIV mortality were greatest for nonwhites, rates remain high among blacks, especially in the lowest educated groups, underscoring the need for additional interventions.

Knowledge, attitudes, and behaviors regarding piperacillin-tazobactam prescribing practices: results from a multicenter study.

We investigated knowledge, attitudes, and behaviors of prescribers concerning piperacillin-tazobactam use at 4 Emory University-affiliated hospitals. Discussions during focus groups indicated that the participants' perceived knowledge of clinical criteria for appropriate piperacillin-tazobactam use was inadequate. Retrospective review of medical records identified inappropriate practices. These findings have influenced ongoing interventions aimed at optimizing piperacillin-tazobactam use.