Isoniazid therapy for Mycobacterium tuberculosis infection in HIV clinics, Los Angeles, California.

SETTING: Publicly funded human immunodeficiency virus (HIV) clinics in Los Angeles County, California, USA. BACKGROUND: HIV-infected persons are a high priority group for targeted testing and treatment for Mycobacterium tuberculosis infection in the United States. OBJECTIVE: To describe rates of isoniazid (INH) initiation and completion among HIV-1 and M. tuberculosis co-infected persons in Los Angeles County. DESIGN: We conducted a cross-sectional study using routinely collected surveillance data from publicly funded HIV clinics. We examined differences in INH treatment initiation and completion between four clinic categories: the three largest clinics (Clinics A, B, and C) and 'Other' clinics (pooled data for the remaining 10 clinics). RESULTS: During 2010-2013, 802 (5.3%) of 15 029 HIV-1-infected persons tested positive for M. tuberculosis infection. INH was initiated in 581 (72.4%) persons, of whom 457 (78.7%) completed treatment. We found significant differences between clinics in terms of treatment initiation (range 59.1-93.4%) and completion (range 58.8-82.3%). Overall, 57% (457/802) of HIV and M. tuberculosis co-infected persons completed the recommended treatment (range across clinics 34.8-76.3%). CONCLUSION: We identified significant gaps in the treatment for M. tuberculosis infection among HIV-infected persons in Los Angeles County. Interventions are needed to improve initiation and completion of treatment for M. tuberculosis infection in this population.

Monitoring HPV type-specific prevalence over time through clinic-based surveillance: a perspective on vaccine effectiveness.

We investigated the feasibility of monitoring trends in prevalence of vaccine-preventable human papillomavirus (HPV) types in different clinic populations. We collected cervical specimens from women presenting to family planning, primary care, and sexually transmitted disease (STD) clinics for routine pap smears in five US cities during 2003-2005. We performed HPV genotyping and calculated annual type-specific prevalences; pre-vaccine era prevalence was highest for HPV 16 (6.0; 95% confidence interval [CI] 5.5-6.6%) and annual prevalences for vaccine-preventable types were stable, with few exceptions, after controlling for clinic type, age group, and city. With sufficient sample size and stable population characteristics, clinic-based surveillance systems can contribute to monitoring HPV vaccine impact in the cervical screening population.

First report of performance of the Versant CT/GC DNA 1.0 assay (kPCR) for detection of Chlamydia trachomatis and Neisseria gonorrhoeae.

We evaluated the analytical, work flow, and clinical performance of the Versant CT/GC DNA 1.0 assay (Versant CT/GC assay, where "CT" represents Chlamydia trachomatis and "GC" represents Neisseria gonorrhoeae). The assay simultaneously detects Chlamydia trachomatis and Neisseria gonorrhoeae in swab and first-catch urine (FCU) specimens. The limit of detection (LoD) was determined to be 342 copies/ml for C. trachomatis and 137 copies/ml for GC. The Versant CT/GC assay detected 15 C. trachomatis serovars and 46 GC strains. The Versant CT/GC assay demonstrated no cross-reactivity with 136 potentially cross-reacting organisms. Clinical concordance of the Versant CT/GC assay to the Aptima Combo 2 (AC2) assay from Gen-Probe was demonstrated using 1,129 patient specimens, including 589 urine and 540 swab specimens. Discrepant specimens were subjected to DNA sequencing to identify the presence of amplified targets and to identify false-positive and false-negative results. Overall percent agreement was greater than 98%. Positive and negative percent agreements for detection of C. trachomatis were 94.4% and 99.1%, respectively, in urine specimens and 95.8% and 99.8%, respectively, in swab specimens. Positive percent agreement for the detection of N. gonorrhoeae was 100% in both urine and swab specimens, and negative percent agreements were 99.6% and 99% in urine and swab specimens, respectively. In conclusion, the performance of the Versant CT/GC assay was comparable to that of the AC2 assay. The Versant CT/GC assay can be recommended for the detection of C. trachomatis and N. gonorrhoeae in swab and urine specimens of symptomatic and asymptomatic individuals.

Circuit parties: sexual behaviors and HIV disclosure practices among men who have sex with men at the White Party, Palm Springs, California, 2003.

The syphilis epidemic among men who have sex with men (MSM) in major US cities and concomitant increases in high-risk sexual behavior, have raised concerns of increased HIV transmission in this population. Therefore, to provide information for health promotion and disease awareness efforts, we investigated sexual behaviors, partner selection preferences and HIV serostatus disclosure practices of MSM at the White Party in Palm Springs, California. Circuit party attendees reported engaging in unprotected anal sex, however, a high proportion reported disclosing their HIV status. These findings suggest that some gay men are serosorting as a risk reduction strategy or implementing sexual risk reduction strategies to protect themselves and their partners. In our study, HIV-negative men were nine times more likely to report a preference for a seroconcordant sexual partner. The self-protecting attitudes of HIV-negative men in our sample outweighed the partner-protecting attitudes of HIV-positive men. This suggests that prevention interventions focusing on HIV-positive persons are warranted.

Comparison of AIDS progression and survival in persons with pulmonary versus extrapulmonary tuberculosis in Los Angeles.

The objective of this research was to compare the demographics, acquired immune deficiency syndrome (AIDS) progression, and survival in persons with AIDS with pulmonary tuberculosis (PTB) versus extrapulmonary tuberculosis (EPTB), because there are limited population-based data on this topic. A population-based longitudinal study with 3 years of follow-up was performed. Data were collected every 6 months from medical records of persons with AIDS and TB treated at private and public medical facilities throughout Los Angeles County (LAC). Participants included a population-based sample of 216 persons with AIDS and PTB and 166 persons with AIDS and EPTB (including 113 persons with both PTB and EPTB), with an AIDS diagnosis reported in 1993. Compared to persons with AIDS with PTB, persons with AIDS and EPTB were 2.2 times more likely to be Latino than white (95% confidence intervals [CIs]: 1.2, 4.0) and 1.7 times more likely to be foreign-born (95% CIs: 1.1, 2.5). Compared to persons with AIDS with PTB, persons with AIDS and EPTB had similar antiretroviral and PCP prophylaxis use; lower CD4 counts at time of AIDS diagnosis (p = 0.0004); no differences in CD4 counts over the total follow-up period (p = 0.4); higher rates of total opportunistic infections (OIs) (incidence density ratio [IDR] = 2.0; 95% CIs: 1.6, 2.4); and comparable survival curves (p = 0.07). Persons with AIDS and EPTB had a more complicated medical course with lower CD4 counts at time of AIDS diagnosis and more OIs over the follow-up period than persons with AIDS and PTB, however the survival profiles for the two groups were comparable.

Incidence and determinants of Pseudomonas aeruginosa infection among persons with HIV: association with hospital exposure.

BACKGROUND: Little information exists on risk factors for Pseudomonas aeruginosa infection in persons with HIV. We assessed the incidence and factors associated with P aeruginosa among persons with HIV enrolled in a large observational cohort study in Los Angeles. METHODS: Data were analyzed from 4825 persons aged > or =13 years with HIV infection enrolled from 4 outpatient facilities from 1990 to 1998. The association between P aeruginosa infection and demographic, risk behavior, and clinical factors was assessed. RESULTS: P aeruginosa was diagnosed in 72 (1.5%) patients representing a crude incidence rate of 0.74 per 100 person-years. The most frequent site of infection was pulmonary (47%). In multivariate analysis, prior hospitalization (adjusted rate ratio = 7.9, 95% CI, 3.8-16.2), and both dapsone (adjusted rate ratio = 4.0, 95% CI, 2.2-7.4) and trimethoprim-sulfamethoxazole (adjusted rate ratio = 2.5, 95% CI, 1.2-5.3) use were independently associated with higher rates of infection. Increasing days of inpatient stay (P <.01) and decreasing CD4(+) counts (P <.01) were strongly associated with P aeruginosa. Azithromycin use decreased the risk of infection by nearly 70%. CONCLUSION: Although the overall observed incidence of P aeruginosa was low, hospital exposure, declining CD4(+) levels, and the use of dapsone or trimethoprim-sulfamethoxazole increased the risk of P aeruginosa disease, and azithromycin use was protective in this population. These findings may assist in the early recognition and diagnosis of persons likely to be at increased risk of P aeruginosa infection.

Prevention of HIV infection in street-recruited injection drug users. The Collaborative Injection Drug User Study (CIDUS).

BACKGROUND: Injection drug users (IDUs) and their sex partners account for an increasing proportion of new AIDS and HIV cases in the United States, but public debate and policy regarding the effectiveness of various HIV prevention programs for them must cite data from other countries, from non-street-recruited IDUs already in treatment, or other programs, and from infection rates for pathogens other than HIV. METHODS: Participants were recruited from the street at six sites (Baltimore [Maryland], New York [two sites], Chicago [Illinois], San Jose [California], Los Angeles [California], and at a state women's correctional facility [Connecticut]), interviewed with a standard questionnaire, and located and reinterviewed at one or more follow-up visits (mean, 7.8 months later). HIV serostatus and participation in various programs and behaviors that could reduce HIV infection risk were determined at each visit. RESULTS: In all, 3773 participants were recruited from the street, and 2306 (61%) were located and interviewed subsequently. Of 3562 initial serum specimens, 520 (14.6%) were HIV-seropositive; at subsequent assessment, 19 people, all from the East Coast and Chicago, had acquired HIV. Not using previously used needles was substantially protective against HIV acquisition (relative risk [RR], 0.29; 95% confidence interval [CI], 0.11-0.80 ) and, in a multivariate model, was significantly associated with use of needle and syringe exchange programs (adjusted odds ratio [ORadj], 2.08; 95% CI, 1.15-3.85). Similarly, reduction of injection frequency was very protective against seroconversion (RR, 0.33; 95% CI, 0.14-0.80), and this behavior was strongly associated with participation in drug treatment programs (ORadj, 3.54; 95% CI, 2.50-5.00). In a separate analysis, only 37.5% of study-participants had sufficient new needles to meet their monthly demand. CONCLUSIONS: In this large multicity study of IDUs in the United States, several HIV prevention strategies appeared to be individually and partially effective; these results indicate the continued need for, and substantial gaps in, effective approaches to preventing HIV infection in drug users.

High-risk behaviors during incarceration in African-American men treated for HIV at three Los Angeles public medical centers.

OBJECTIVES: This paper describes research that examined the association between high-risk sexual and drug-using behaviors during incarceration and HIV infection for African-American men receiving HIV care at three public medical centers in Los Angeles County (LAC), California. METHODS: A case-control study was conducted in which 305 HIV-infected African-American men and 305 neighborhood controls, ages 20 to 49, were frequency-matched by age. RESULTS: After controlling for anal sex while not incarcerated, we found no association between anal sex during incarceration and HIV (odds ratio [OR], 1.1; 95% confidence interval [CI], 0.6-2.2). Among men with a history of incarceration (n = 332), the percentage reporting anal sex with men outside of incarceration (45%) was greater than those reporting anal sex while incarcerated (16%). Injection drug use (IDU) during incarceration was also not associated with HIV when controlling for IDU outside of incarceration (OR, 1.6; 95% CI, 0.5- 4.9). Increased time in jail or prison was associated with less HIV infection (p =.001). CONCLUSIONS: Although high-risk behaviors are more common in the community than in the incarcerated setting for this study group, incarcerated populations represent a high-risk group for whom access to prevention messages is limited. Periods of incarceration represent a unique opportunity to convey prevention messages that focus on high-risk behaviors outside the incarcerated setting.

Prevalence of unprotected sex among men with AIDS in Los Angeles County, California 1995-1997.

OBJECTIVE: To determine the prevalence of unprotected sex among men with AIDS in Los Angeles County. DESIGN: Cross-sectional study. METHODS: All men aged > or = 18 years who were newly reported to the local health department with AIDS and completed a standardized interview between January 1995 and June 1997 were included in the study. Men were classified as having unprotected sex if they reported one or more sex partners during the past year with whom they had vaginal or anal sex and did not always use a condom. RESULTS: Of 617 men interviewed, 29% reported unprotected sex in the past year. The prevalence of unprotected sex was highest among men < 30 years of age (43%) and those who had first learned of their HIV-positive status < 12 months prior to interview (44%). In all, 323 (52%) men reported one or more male sex partners in the past year. Of these, 22% reported unprotected insertive anal sex and 27% unprotected receptive anal sex. One or more female partners in the past year was reported by 131 (21%) men. Of these, 53% reported unprotected vaginal sex and 18% unprotected anal sex. CONCLUSIONS: The findings highlight the importance of early HIV detection efforts, coupled with targeted and sustained HIV prevention services for those who test positive, to prevent ongoing transmission of the virus.

Sociodemographic and behavioral characteristics of African-American women with HIV and AIDS in Los Angeles County, 1990-1997.

African-American women have the highest AIDS rate of any racial/ethnic group of women in both Los Angeles County (LAC), California and in the United States. Limited population-based epidemiologic studies of African-American women with HIV and AIDS describe this group and examine the factors associated with the excessive rates. Interview data collected from 1990 to 1997 on a population-based sample of AIDS cases and a group of HIV-infected women in LAC were analyzed to highlight the sociodemographic and behavioral characteristics of African-American women. This group of African-American women with HIV or AIDS in LAC were unemployed (88%), single mothers (64%), living on public assistance (86%) with annual household incomes <$10,000 U.S. (76%). A history of crack use predominated (50%). Compared with women of other races with HIV and AIDS, African-American women reported more sexual partners; reported more infections with sexually transmitted diseases; sought treatment for their HIV infection later; were more likely to trade sex; and were almost five times more likely to have ever used crack cocaine. HIV prevention for African-American women in LAC should focus on improving self-esteem and negotiation skills within the context of the crack cocaine culture and the disadvantaged social and economic situation described.

Seasonality and factors associated with cryptosporidiosis among individuals with HIV infection.

The seasonality and factors associated with Cryptosporidium infection were assessed in a cohort of HIV-infected patients in Los Angeles County to better define the epidemiology of cryptosporidiosis among individuals with HIV. Data were analysed from a cohort of 4247 patients > or = 13 years of age with HIV infection enrolled from four outpatient facilities in Los Angeles, 1990-6. Cryptosporidiosis was diagnosed in 120 (2.8%) patients. Among the 1296 individuals with complete follow-up until death, cryptosporidiosis occurred in 69 (5.3%). The seasonal rate of cryptosporidiosis showed a modest bimodal trend with the highest rates occurring in March-May and September-October. There was no difference in the rate of cryptosporidiosis for the periods of heaviest rainfall (December-March) and low rainfall (April-November). Infection rates were higher among males (1.59 per 100 person-years) than females (0.92) and lower in blacks (0.98) than other racial/ethnic groups (1.80). A significant trend of decreasing cryptosporidiosis was observed with increasing age, with the highest rate (2.34) in the 13-34 year age group. A strong association between cryptosporidiosis and CD4+ count was noted. These data suggest that cryptosporidiosis among HIV-infected individuals in Los Angeles County exhibits a modest spring and fall seasonality. This pattern of occurrence of cryptosporidiosis appears temporally unrelated to local rainfall patterns. Our findings suggest that HIV-infected men, individuals in younger age groups and those with CD4+ lymphocyte counts < 100 x 10(6)/l are at increased risk of cryptosporidiosis. Blacks with HIV infection appear less likely than other racial/ethnic groups to be diagnosed with Cryptosporidium infection. These results may provide insight into possible routes of transmission and sources of cryptosporidiosis infection in individuals with HIV.

Incidence and factors associated with extrapulmonary cryptococcosis among persons with HIV infection in Los Angeles County.

OBJECTIVE: To determine the incidence and factors associated with extrapulmonary cryptococcosis among a cohort of persons with HIV in Los Angeles County. DESIGN: Records-based cohort study. METHODS: Data were analysed from a cohort of 3836 persons aged > or = 13 years with HIV infection enrolled from four outpatient facilities in Los Angeles from 1990 to 1995. The potential association between cryptococcosis and demographic risk behavior and clinical factors was assessed. Possible seasonal clustering was evaluated and an estimate of survival following cryptococcosis was calculated. Multivariate analysis was performed using a Cox proportional hazards approach. RESULTS: Cryptococcosis was identified in 112 patients (2.9%) representing a crude incidence rate of 1.7 cases per 100 person-years experience. The rate of cryptococcosis was higher among men than women (1.9 and 0.6, respectively; P < 0.01) and in Hispanics than in whites (2.3 and 1.2, respectively, P < 0.01). A significant trend of decreasing cryptococcosis was observed with increasing age (P < 0.01). Cryptococcosis increased with declining CD4+ lymphocyte count, with risk being greatest at CD4+ cell counts below 100 x 10(6)/l (P < 0.001). In bivariate analysis persons with a history of antifungal medication had a marginally lower rate of cryptococcosis, but this difference was not statistically significant. The rate of cryptococcosis was significantly higher in fall and winter months [rate ratio (RR), 1.45; 95% confidence interval (CI), 1.0-2.3; P = 0.05]. After controlling for other variables, cryptococcosis was more common in men than women (adjusted RR, 3.2; 95% CI, 1.0-10.4) and in Hispanics than whites (adjusted RR, 1.6; 95% CI, 0.9-2.7). Both CD4+ count and age continued to be strongly associated with the occurrence of cryptococcosis. After controlling for other factors a substantial protective effect was observed for antifungal therapy (adjusted RR, 0.48; 95% CI, 0.29-0.79). CONCLUSION: Our data suggest that HIV-infected men, Hispanics, persons aged under 45 years and those with CD4+ counts under 100 x 10(6)/l have an increased risk of extrapulmonary cryptococcosis. A fall-winter seasonality in the occurrence of cryptococcosis may exist. Significant primary protection against cryptococcal disease is afforded by antifungal therapy. These results may provide insight into possible routes of transmission and sources of cryptococcal infection and help guide both primary prophylaxis and early recognition and diagnosis in persons likely to be at increased risk.

A probability-based approach for predicting HIV infection in a low prevalent population of injection drug users.

This article proposes a method for estimating HIV risk in low-HIV-prevalent populations. Allard's risk probability model was used to compute individual risk scores. Based on a sample of 3854 injection drug users (IDUs) who were confidentially tested for HIV at five methadone treatment clinics in Los Angeles County, the following self-reported risk behaviors were used to derive an individual IDU risk score: (i) frequency of injection, (ii) frequency of using uncleaned needles, (iii) number of people sharing a needle, (iv) frequency of needle sharing, and (v) type of needle sharing practice. The overall HIV prevalence for the IDU sample was 2%. The risk score was strongly associated with HIV seropositivity (chi-square = 16.1, p < 0.0001), but only one of the individual IDU risk behaviors (needle cleaning) was significantly associated with HIV seropositivity (chi-square = 10.9, P < 0.001). In addition, the risk score was strongly associated with HIV serostatus for both males and females. For females, however, none of the individual IDU risk behaviors were associated with HIV serostatus. Our findings indicate that when predicting HIV infection in a low-prevalence population, the probability-based risk score makes a statistically significant contribution over individual IDU risk behaviors.

Reasons for HIV antibody test refusal in a heterosexual sexually transmitted disease clinic population.

OBJECTIVE: To evaluate acceptance of confidential HIV antibody testing and reasons for test refusal among heterosexual clients of Los Angeles County sexually transmitted disease (STD) clinics. METHODS: From January 1993 through June 1994, all blood specimens routinely collected for syphilis serology were tested blindly for HIV antibody at seven STD clinics. Patients were counseled and offered a confidential HIV test. Rate of refusal of confidential testing and primary reason for test refusal were examined by demographic group and HIV serostatus, as determined in the blinded survey, for all heterosexual clients. RESULTS: Of 20,125 persons offered confidential testing, 35.6% refused the test. Test refusal was higher among men (38.7%) than women [31.1%; adjusted odds ratio (OR), 1.4; 95% confidence interval (CI), 1.3-1.4] and among blacks (38.6%) than whites (28.6%; adjusted OR, 1.7; 95% CI, 1.5-2.0). The most common reason for refusal was 'already know my HIV status' (40.6%), followed by 'don't want to know' (23.9%), and 'not at risk' (19.4%). Confidentiality concerns were cited as the primary reason for refusal by 2.2%. Among the 180 (0.9%) persons who tested positive in the blinded survey, 99 (55.0%) refused the confidential test. Of the 44 seropositive persons who refused the confidential test because they "already knew their HIV status', 29 (65.9%) reported their previous test to be negative. CONCLUSIONS: Efforts are needed to increase acceptance of confidential HIV testing in this heterosexual population and should (1) include a client-centered counseling approach that facilitates accurate self-assessment of risk and addresses the misperception that a prior negative test result implies an absence of risk, and (2) highlight the potential benefits of early intervention medical and psychosocial services.

Unrecognized HIV-1 infection in inner-city hospital emergency department patients.

To determine the prevalence of unrecognized human immunodeficiency virus (HIV)-1 infections in patients presenting to an inner-city hospital emergency department, medical records were reviewed from 1,945 patients diagnosed with diseases not related to HIV or acquired immunodeficiency syndrome. The overall seroprevalence was 2.1% (40): 1.8% (11) in nontrauma versus 3.0% (29) in trauma patients. The highest prevalence was found in black, male, uninsured patients.

Occupational risk of acquiring HIV infection through needlestick injuries.

Accidental needlestick exposures occur frequently among hospital personnel and account for most incidents of percutaneous injuries. Even if universal precautions were followed routinely, it is unlikely that multiple needlestick exposures could be avoided completely. Despite the likelihood of persons incurring multiple needlestick exposures, relatively little information is available on the cumulative risk of human immunodeficiency virus (HIV) infection for health care workers attending unrecognized HIV-infected patients. A quantitative method to estimate annual cumulative risk from multiple exposures is offered, and the risk of HIV infection is estimated by use of a probability model for health care workers in both hospital and emergency department settings.