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1.
J Int AIDS Soc ; 22(9): e25392, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31507083

RESUMO

INTRODUCTION: Extrapulmonary tuberculosis (EPTB) is difficult to confirm bacteriologically and requires specific diagnostic capacities. Diagnosis can be especially challenging in under-resourced settings. We studied diagnostic modalities and clinical outcomes of EPTB compared to pulmonary tuberculosis (PTB) among HIV-positive adults in antiretroviral therapy (ART) programmes in low- and middle-income countries (LMIC). METHODS: We collected data from HIV-positive TB patients (≥16 years) in 22 ART programmes participating in the International Epidemiology Databases to Evaluate AIDS (IeDEA) consortium in sub-Saharan Africa, Asia-Pacific, and Caribbean, Central and South America regions between 2012 and 2014. We categorized TB as PTB or EPTB (EPTB included mixed PTB/EPTB). We used multivariable logistic regression to assess associations with clinical outcomes. RESULTS AND DISCUSSION: We analysed 2695 HIV-positive TB patients. Median age was 36 years (interquartile range (IQR) 30 to 43), 1102 were female (41%), and the median CD4 count at TB treatment start was 114 cells/µL (IQR 40 to 248). Overall, 1930 had PTB (72%), and 765 EPTB (28%). Among EPTB patients, the most frequently involved sites were the lymph nodes (24%), pleura (15%), abdomen (11%) and meninges (6%). The majority of PTB (1123 of 1930, 58%) and EPTB (582 of 765, 76%) patients were diagnosed based on clinical criteria. Bacteriological confirmation (using positive smear microscopy, culture, Xpert MTB/RIF, or other nucleic acid amplification tests result) was obtained in 897 of 1557 PTB (52%) and 183 of 438 EPTB (42%) patients. EPTB was not associated with higher mortality compared to PTB (adjusted odd ratio (aOR) 1.0, 95% CI 0.8 to 1.3), but TB meningitis was (aOR 1.9, 95% CI 1.0 to 3.1). Bacteriological confirmation was associated with reduced mortality among PTB patients (aOR 0.7, 95% CI 0.6 to 0.8) and EPTB patients (aOR 0.3 95% CI 0.1 to 0.8) compared to TB patients with a negative test result. CONCLUSIONS: Diagnosis of EPTB and PTB at ART programmes in LMIC was mainly based on clinical criteria. Greater availability and usage of TB diagnostic tests would improve the diagnosis and clinical outcomes of both EPTB and PTB.

2.
AIDS Behav ; 2019 Aug 27.
Artigo em Inglês | MEDLINE | ID: mdl-31456198

RESUMO

Client-level data from two Tennessee-based PrEP navigation demonstration projects reported to the Tennessee Department of Health from January to December 2017 were evaluated to determine the proportion of clients who accepted, were linked to, and were prescribed PrEP. Disparities by age, race, transmission risk, and geographic region as well as trends over time were examined via bivariate and multivariable modified Poisson regression models accounting for potential confounders. Among 1385 PrEP-eligible individuals, 50.5% accepted, 33.4% were linked, and 27.3% were prescribed PrEP. PrEP uptake varied by age, race, and HIV transmission risk, and most disparities persisted across Tennessee throughout evaluation period. Multivariable regression models revealed significant independent associations between age, race/ethnicity, transmission risk, and region and PrEP acceptance and linkage. While differences in PrEP acceptance by race narrowed over time, success among black MSM was limited, underscoring a significant need to improve upstream PrEP continuum outcomes for this important population.

3.
Am J Public Health ; 109(9): 1266-1272, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31318589

RESUMO

Objectives. To use statewide surveillance data to examine trends and disparities in mortality and progression from HIV to AIDS comprehensively in Tennessee over the past 20 years.Methods. Individuals diagnosed with HIV in Tennessee from 1996 to 2016 were identified through the Tennessee Department of Health Enhanced HIV/AIDS Reporting System. Clinical AIDS and all-cause mortality were the outcomes. Cox regression yielded adjusted hazard ratios (AHRs) for death and competing risk regression yielded adjusted subhazard ratios (SHRs) for AIDS, with death as the competing event.Results. Individuals with a history of heterosexual contact (AHR = 1.20; 95% confidence interval [CI] = 1.12, 1.29) and injection drug use (AHR = 1.27; 95% CI = 1.18, 1.38) had increased hazards of death relative to those with a history of male-to-male sexual contact. Hazards of death were lower among White (AHR = 0.79; 95% CI = 0.73, 0.85) and Hispanic (AHR = 0.50; 95% CI = 0.40, 0.63) individuals than among Black individuals. Those with heterosexual contact (SHR = 1.20; 95% CI = 1.12, 1.29) and injection drug use (SHR = 1.27; 95% CI = 1.18, 1.38) had a greater risk of AIDS than those with male-to-male sexual contact. White individuals (SHR = 0.85; 95% CI = 0.81, 0.90) had a lower risk of AIDS than Black individuals, and female individuals (SHR = 0.84; 95% CI = 0.79, 0.90) had a lower risk than male individuals.Conclusions. The trends, disparities, and outcomes assessed in our study will inform HIV testing and care linkage program design and implementation in Tennessee.

5.
Public Health Rep ; 133(2_suppl): 43S-51S, 2018 Nov/Dec.
Artigo em Inglês | MEDLINE | ID: mdl-30457951

RESUMO

OBJECTIVES:: Tennessee was 1 of 8 states that received funding from the Care and Prevention in the United States Demonstration Project, which aimed to reduce HIV-related morbidity and mortality among racial/ethnic and sexual minority populations. The objective of this study was to describe implementation of a social network strategy (SNS) program, which leverages personal connections in social networks, to reach people with undiagnosed HIV infection for HIV testing. We targeted young black men who have sex with men (MSM) at 3 agencies in Memphis and Nashville, Tennessee, during 2013-2016. METHODS:: Specialists at the 3 agencies identified MSM with and without diagnosed HIV infection (ie, recruiters) who could recruit members from their social networks for HIV testing (ie, network associates). Both recruiters and network associates received OraQuick rapid and confirmatory HIV tests. We used χ2 and Fisher exact tests to assess differences in demographic characteristics, HIV testing, and care engagement status by agency. RESULTS:: Of 1752 people who were tested for HIV in the SNS program, 158 (9.0%) tested positive; of these, 80 (50.6%) were newly diagnosed with HIV. Forty-seven of the 78 (60.3%) people who were previously diagnosed with HIV were not in care in the previous 12 months; of these, 27 (57.4%) were reengaged in medical care. Of 80 people newly diagnosed with HIV, 44 (55.0%) were linked to care. CONCLUSIONS:: The SNS program ascertained HIV status among a high-risk population in a heavily burdened region. Further program evaluation is needed to understand how to improve linkage to care among people with newly diagnosed HIV.

6.
Curr Opin HIV AIDS ; 13(6): 469-477, 2018 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-30222609

RESUMO

PURPOSE OF REVIEW: The present review describes recent advances in the treatment of drug-susceptible tuberculosis (DS-TB) among people living with human immunodeficiency virus (PLWH). RECENT FINDINGS: Higher than standard rifampicin doses (>10 mg/kg/day) are well tolerated and have improved sterilizing activity. Standard pyrazinamide doses may result in low drug exposures; modeling reveals that higher doses (>25 mg/kg/day) may be required to reach target levels, although safety is unknown. Four-month fluoroquinolone-containing regimens are not recommended in the 2017 World Health Organization DS-TB treatment guidelines. These guidelines also recommend fixed-dose combination (FDC) therapy over single drug formulations based on patient preference, though FDC is not associated with improved outcomes. Treatment for 6 months is recommended, with an emphasis on expanded antiretroviral therapy (ART) coverage and monitoring for relapse among those not started on ART within 8 weeks of tuberculosis treatment. Directly observed therapy (DOT) is recommended over self-administered therapy, as is daily therapy over intermittent therapy - both are associated with better tuberculosis outcomes. SUMMARY: Current WHO tuberculosis treatment guidelines recommend 6 months of daily tuberculosis treatment for PLWH who have DS-TB, and timely ART initiation. Higher rifampin and pyrazinamide doses may enhance treatment effectiveness, but safety data are needed. DOT and FDC therapy are recommended.

7.
Thorax ; 73(11): 1062-1070, 2018 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-29982223

RESUMO

BACKGROUND: Lack of a gold standard for latent TB infection has precluded direct measurement of test characteristics of the tuberculin skin test and interferon-γ release assays (QuantiFERON Gold In-Tube and T-SPOT.TB). OBJECTIVE: We estimated test sensitivity/specificity and latent TB infection prevalence in a prospective, US-based cohort of 10 740 participants at high risk for latent infection. METHODS: Bayesian latent class analysis was used to estimate test sensitivity/specificity and latent TB infection prevalence among subgroups based on age, foreign birth outside the USA and HIV infection. RESULTS: Latent TB infection prevalence varied from 4.0% among foreign-born, HIV-seronegative persons aged <5 years to 34.0% among foreign-born, HIV-seronegative persons aged ≥5 years. Test sensitivity ranged from 45.8% for the T-SPOT.TB among foreign-born, HIV-seropositive persons aged ≥5 years to 80.7% for the tuberculin skin test among foreign-born, HIV-seronegative persons aged ≥5 years. The skin test was less specific than either interferon-γ release assay, particularly among foreign-born populations (eg, the skin test had 70.0% specificity among foreign-born, HIV-seronegative persons aged ≥5 years vs 98.5% and 99.3% specificity for the QuantiFERON and T-SPOT.TB, respectively). The tuberculin skin test's positive predictive value ranged from 10.0% among foreign-born children aged <5 years to 69.2% among foreign-born, HIV-seropositive persons aged ≥5 years; the positive predictive values of the QuantiFERON (41.4%) and T-SPOT.TB (77.5%) were also low among US-born, HIV-seropositive persons aged ≥5 years. CONCLUSIONS: These data reinforce guidelines preferring interferon-γ release assays for foreign-born populations and recommending against screening populations at low risk for latent TB infection. TRIAL REGISTRATION NUMBER: NCT01622140.

8.
AIDS Behav ; 22(8): 2604-2614, 2018 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-29560569

RESUMO

Studies evaluating the association between human immunodeficiency virus (HIV) infection continuum of care outcomes [antiretroviral (ART) adherence, retention in care, viral suppression] and health literacy have yielded conflicting results. Moreover, studies from the southern United States, a region of the country disproportionately affected by the HIV epidemic and low health literacy, are lacking. We conducted an observational cohort study among 575 people living with HIV (PLWH) at the Vanderbilt Comprehensive Care Clinic (Nashville, Tennessee). Health literacy was measured using the brief health literacy screen, a short tool which can be administered verbally by trained clinical personnel. Low health literacy was associated with a lack of viral suppression, but not with poor ART adherence or poor retention. Age and racial disparities in continuum of care outcomes persisted after accounting for health literacy, suggesting that factors in addition to health literacy must be addressed in order to improve outcomes for PLWH.

9.
J Int AIDS Soc ; 21(1)2018 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-29334197

RESUMO

INTRODUCTION: HIV-1 infection leads to chronic inflammation and to an increased risk of non-AIDS mortality. Our objective was to determine whether AIDS-defining events (ADEs) were associated with increased overall and cause-specific non-AIDS related mortality after antiretroviral therapy (ART) initiation. METHODS: We included HIV treatment-naïve adults from the Antiretroviral Therapy Cohort Collaboration (ART-CC) who initiated ART from 1996 to 2014. Causes of death were assigned using the Coding Causes of Death in HIV (CoDe) protocol. The adjusted hazard ratio (aHR) for overall and cause-specific non-AIDS mortality among those with an ADE (all ADEs, tuberculosis (TB), Pneumocystis jiroveci pneumonia (PJP), and non-Hodgkin's lymphoma (NHL)) compared to those without an ADE was estimated using a marginal structural model. RESULTS: The adjusted hazard of overall non-AIDS mortality was higher among those with any ADE compared to those without any ADE (aHR 2.21, 95% confidence interval (CI) 2.00 to 2.43). The adjusted hazard of each of the cause-specific non-AIDS related deaths were higher among those with any ADE compared to those without, except metabolic deaths (malignancy aHR 2.59 (95% CI 2.13 to 3.14), accident/suicide/overdose aHR 1.37 (95% CI 1.05 to 1.79), cardiovascular aHR 1.95 (95% CI 1.54 to 2.48), infection aHR (95% CI 1.68 to 2.81), hepatic aHR 2.09 (95% CI 1.61 to 2.72), respiratory aHR 4.28 (95% CI 2.67 to 6.88), renal aHR 5.81 (95% CI 2.69 to 12.56) and central nervous aHR 1.53 (95% CI 1.18 to 5.44)). The risk of overall and cause-specific non-AIDS mortality differed depending on the specific ADE of interest (TB, PJP, NHL). CONCLUSIONS: In this large multi-centre cohort collaboration with standardized assignment of causes of death, non-AIDS mortality was twice as high among patients with an ADE compared to without an ADE. However, non-AIDS related mortality after an ADE depended on the ADE of interest. Although there may be unmeasured confounders, these findings suggest that a common pathway may be independently driving both ADEs and NADE mortality. While prevention of ADEs may reduce subsequent death due to NADEs following ART initiation, modification of risk factors for NADE mortality remains important after ADE survival.

10.
AIDS Res Hum Retroviruses ; 33(10): 1027-1034, 2017 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-28462622

RESUMO

Longitudinal studies of retention in care (RIC) and viral suppression (VS) in the southeastern United States (US), a region disproportionately affected by HIV infection, are lacking. HIV-infected adults with ≥1 medical visit at the Vanderbilt Comprehensive Care Clinic (Nashville, Tennessee) from 2004 to 2013 were included. RIC was ≥2 (a) laboratory dates [CD4+ counts or HIV-1 viral loads (VLs)] or (b) provider encounters and/or laboratory dates in the year of interest, ≥90 days apart. VS was a VL of <200 copies/ml at last measurement in the year of interest. Modified Poisson regression estimated relative risk (RR) of RIC and VS, adjusting for age, race, sex, HIV transmission risk, and socioeconomic status (SES). Among 4,641 persons, 76.8% achieved RIC and 70.2% achieved VS. RIC and VS increased from 2004 to 2013 (p < .001 each). For lack of RIC, younger patients (RR = 1.2 and RR = 1.1, 18-24 and 25-34 vs. 35-44 year-olds, respectively), Blacks (RR = 1.3 vs. Whites), and injection drug users (IDUs) (RR = 1.2 vs. heterosexual contact [Hetero]) fared worse (p < .05 each); those with male-to-male sexual contact fared better (RR = 0.8 vs. Hetero, p < .05). For lack of VS, younger patients (RR = 1.3 and RR = 1.2, 18-24 and 25-34 vs. 35-44 year olds, respectively), Blacks (RR 1.3 vs. Whites), Females (RR = 1.1 vs. Males), IDUs (RR 1.3 vs. Hetero), and those with low SES (RR = 1.1 vs. not low SES) fared worse (p < .05, each). RIC and VS increased over time, suggesting that efforts to improve outcomes have been effective. However, disparities persist and resources should focus on groups most at risk.


Assuntos
Fármacos Anti-HIV/uso terapêutico , Continuidade da Assistência ao Paciente/tendências , Infecções por HIV/tratamento farmacológico , Cooperação do Paciente/estatística & dados numéricos , Assistência Centrada no Paciente/métodos , Adolescente , Adulto , Idoso , Feminino , Seguimentos , Infecções por HIV/transmissão , Infecções por HIV/virologia , HIV-1/efeitos dos fármacos , Humanos , Estudos Longitudinais , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Comportamento Sexual , Sudeste dos Estados Unidos , Resultado do Tratamento , Carga Viral , Adulto Jovem
11.
J Microbiol Methods ; 136: 65-70, 2017 05.
Artigo em Inglês | MEDLINE | ID: mdl-28285168

RESUMO

Urine samples are increasingly used for diagnosing infections including Escherichia coli, Ebola virus, and Zika virus. However, extraction and concentration of nucleic acid biomarkers from urine is necessary for many molecular detection strategies such as polymerase chain reaction (PCR). Since urine samples typically have large volumes with dilute biomarker concentrations making them prone to false negatives, another impediment for urine-based diagnostics is the establishment of appropriate controls particularly to rule out false negatives. In this study, a mouse glyceraldehyde 3-phosphate dehydrogenase (GAPDH) DNA target was added to retrospectively collected urine samples from tuberculosis (TB)-infected and TB-uninfected patients to indicate extraction of intact DNA and removal of PCR inhibitors from urine samples. We tested this design on surrogate urine samples, retrospective 1milliliter (mL) urine samples from patients in Lima, Peru and retrospective 5mL urine samples from patients in Cape Town, South Africa. Extraction/PCR control DNA was detectable in 97% of clinical samples with no statistically significant differences among groups. Despite the inclusion of this control, there was no difference in the amount of TB IS6110 Tr-DNA detected between TB-infected and TB-uninfected groups except for samples from known HIV-infected patients. We found an increase in TB IS6110 Tr-DNA between TB/HIV co-infected patients compared to TB-uninfected/HIV-infected patients (N=18, p=0.037). The inclusion of an extraction/PCR control DNA to indicate successful DNA extraction and removal of PCR inhibitors should be easily adaptable as a sample preparation control for other acellular sample types.


Assuntos
DNA/isolamento & purificação , Marcadores Genéticos , Camundongos/genética , Técnicas de Diagnóstico Molecular/métodos , Mycobacterium tuberculosis/genética , Reação em Cadeia da Polimerase/métodos , Tuberculose/urina , Urina/microbiologia , Animais , Sequência de Bases , Coinfecção , Marcação de Genes/métodos , Gliceraldeído-3-Fosfato Desidrogenases/genética , Infecções por HIV/complicações , Humanos , Mycobacterium tuberculosis/isolamento & purificação , Fragmentos de Peptídeos/genética , Estudos Retrospectivos , Sensibilidade e Especificidade , África do Sul , Tuberculose/complicações , Tuberculose/diagnóstico , Tuberculose/microbiologia
12.
J Acquir Immune Defic Syndr ; 75(2): 156-163, 2017 Jun 01.
Artigo em Inglês | MEDLINE | ID: mdl-28234689

RESUMO

INTRODUCTION: Management of tuberculosis (TB) is challenging in HIV/TB-coinfected children. The World Health Organization recommends nucleic acid amplification tests for TB diagnosis, a 4-drug regimen including ethambutol during intensive phase (IP) of treatment, and initiation of antiretroviral therapy (ART) within 8 weeks of TB diagnosis. We investigated TB treatment outcomes by diagnostic modality, IP regimen, and ART status. METHODS: We conducted a retrospective cohort study among HIV/TB-coinfected children enrolled at the International Epidemiology Databases to Evaluate AIDS treatment sites from 2012 to 2014. We modeled TB outcome using multivariable logistic regression including diagnostic modality, IP regimen, and ART status. RESULTS: Among the 386 HIV-infected children diagnosed with TB, 20% had microbiologic confirmation of TB, and 20% had unfavorable TB outcomes. During IP, 78% were treated with a 4-drug regimen. Thirty-one percent were receiving ART at the time of TB diagnosis, and 32% were started on ART within 8 weeks of TB diagnosis. Incidence of ART initiation within 8 weeks of TB diagnosis was higher for those with favorable TB outcomes (64%) compared with those with unfavorable outcomes (40%) (P = 0.04). Neither diagnostic modality (odds ratio 1.77; 95% confidence interval: 0.86 to 3.65) nor IP regimen (odds ratio 0.88; 95% confidence interval: 0.43 to 1.80) was associated with TB outcome. DISCUSSION: In this multinational study of HIV/TB-coinfected children, many were not managed as per World Health Organization guidelines. Children with favorable TB outcomes initiated ART sooner than children with unfavorable outcomes. These findings highlight the importance of early ART for children with HIV/TB coinfection, and reinforce the need for implementation research to improve pediatric TB management.


Assuntos
Fármacos Anti-HIV/uso terapêutico , Antituberculosos/uso terapêutico , Coinfecção/tratamento farmacológico , Bases de Dados Factuais , Infecções por HIV/tratamento farmacológico , Tuberculose/tratamento farmacológico , África ao Sul do Saara/epidemiologia , Ásia Sudeste/epidemiologia , Contagem de Linfócito CD4 , Criança , Pré-Escolar , Coinfecção/epidemiologia , Feminino , Infecções por HIV/epidemiologia , Humanos , Lactente , Masculino , Modelos de Riscos Proporcionais , Estudos Retrospectivos , Resultado do Tratamento , Tuberculose/epidemiologia , Carga Viral , Organização Mundial da Saúde
13.
J Public Health Manag Pract ; 23(6): 581-588, 2017 Nov/Dec.
Artigo em Inglês | MEDLINE | ID: mdl-27997480

RESUMO

CONTEXT: In the United States, state laws require health care providers to report specific diseases and events to public health authorities, a fundamental facet of disease surveillance. However, reporting by providers is often inconsistent, infrequent, and delayed. OBJECTIVE: To examine knowledge, attitudes, and practices regarding provider disease reporting and to understand current barriers to provider disease reporting. DESIGN: A cross-sectional study was conducted via an anonymous, standardized electronic survey. SETTING: The survey was conducted at Vanderbilt University Medical Center, a large, tertiary academic medical center in Nashville, Tennessee. PARTICIPANTS: Health care providers in 4 specialties (internal medicine, pediatrics, obstetrics-gynecology, and emergency medicine). MAIN OUTCOME MEASURE(S): Knowledge of and attitudes regarding provider reporting of diseases to public health authorities in Tennessee. RESULTS: The majority of providers acknowledged they cared for patients with reportable diseases (362/435, 83.2%) and believed that it was their responsibility to report to public health authorities (429/436, 98.4%); however, less than half had ever reported a case (206/436, 47.2%). The median percent correct on the knowledge assessment of Tennessee reportable diseases and conditions was 81.3% (interquartile range = 68.8-87.5). Providers cited a lack of knowledge of which diseases are reportable (186/429, 43.3%) and the logistics of reporting (153/429, 35.7%) as the primary barriers for compliance. CONCLUSION: Most providers acknowledged they cared for patients with reportable diseases and believed they had an obligation to report to public health authorities. However, a lack of knowledge about reporting was frequently described as a limitation to report effectively. Many knowledge deficits were significantly greater among residents than other providers.The policy and practice implications of these findings include a demonstrated need for education of providers about disease reporting as well as development of more convenient reporting mechanisms. Fundamental knowledge of reportable disease requirements and procedures is critical for participation in the broader public health system.


Assuntos
Conhecimentos, Atitudes e Prática em Saúde , Pessoal de Saúde/psicologia , Notificação de Abuso , Estudos Transversais , Pessoal de Saúde/normas , Humanos , Vigilância da População/métodos , Saúde Pública/métodos , Pesquisa Qualitativa , Inquéritos e Questionários , Tennessee
14.
J Acquir Immune Defic Syndr ; 72(5): 572-8, 2016 Aug 15.
Artigo em Inglês | MEDLINE | ID: mdl-27049511

RESUMO

BACKGROUND: Tuberculosis (TB) risk and mortality increase in the 6 months after highly active antiretroviral therapy (HAART) initiation. This short-term risk may be a consequence of HAART initiation and immune reconstitution. Alternatively, it may be due to confounding by low CD4 counts and high HIV viral loads (VLs). We assessed the TB risk before and after HAART initiation while appropriately controlling for time-updated laboratory values and HAART exposure. METHODS: We conducted an observational cohort study among persons enrolled in the North American AIDS Cohort Collaboration on Research and Design from 1998 through 2011. A marginal structural model was constructed to estimate the association of HAART initiation and TB risk. Inverse probability weights for the probability of HAART initiation were incorporated. RESULTS: Among 26,342 patients, 94 cases of TB were diagnosed during 147,557 person-years (p-y) of follow-up. The unadjusted TB rates were 93/100,000 p-y [95% confidence interval (CI): 63 to 132] before HAART initiation, 203/100,000 p-y (95% CI: 126 to 311) ≤6 months after HAART initiation, and 40/100,000 p-y (95% CI: 29 to 55) >6 months on HAART. After controlling for time-updated laboratory values, the adjusted odds of TB ≤6 months after HAART initiation and >6 months was 0.65 (95% CI: 0.28 to 1.51) and 0.29 (95% CI: 0.16 to 0.53), respectively. CONCLUSIONS: TB risk in the first 6 months after HAART initiation is not higher than that before HAART initiation after adjusting for CD4 count and VLs. These findings suggest that short-term TB risk may be related to low CD4 counts and high VLs near HAART initiation and support early HAART initiation to decrease TB risk.


Assuntos
Terapia Antirretroviral de Alta Atividade , Coinfecção/imunologia , Infecções por HIV/tratamento farmacológico , Infecções por HIV/imunologia , Síndrome Inflamatória da Reconstituição Imune/imunologia , Tuberculose/complicações , Carga Viral/efeitos dos fármacos , Terapia Antirretroviral de Alta Atividade/efeitos adversos , Terapia Antirretroviral de Alta Atividade/métodos , Contagem de Linfócito CD4 , Coinfecção/complicações , Esquema de Medicação , Infecções por HIV/complicações , Infecções por HIV/virologia , Humanos , Síndrome Inflamatória da Reconstituição Imune/virologia , América do Norte , Fatores de Tempo , Tuberculose/imunologia
15.
Public Health Rep ; 131(5): 695-703, 2016 09.
Artigo em Inglês | MEDLINE | ID: mdl-28123210

RESUMO

OBJECTIVES: We measured patient engagement in the human immunodeficiency virus (HIV) continuum of care in Tennessee after implementation of enhanced surveillance activities to assess progress toward 2015 statewide goals. We also examined subgroup disparities to identify groups at risk for poor outcomes. METHODS: We estimated linkage to care, retention in care, and viral suppression among HIV-infected people in Tennessee in 2013, overall and by subgroup, after implementation of enhanced laboratory reporting, address verification, and death-matching procedures. RESULTS: Of 792 people newly diagnosed with HIV infection in 2013, 632 (79.8%) were linked to care, close to the 2015 goal of ≥80%. Of 15 473 people living and diagnosed with HIV infection before 2013, 8458 (54.7%) were retained in care, approaching the 2015 goal of ≥64.0%. A total of 8640 (55.8%) were virally suppressed, surpassing the 2015 goal of ≥51.0%. Compared with people living and diagnosed with HIV infection before 2013, newly diagnosed people were more likely to be younger, male, non-Hispanic black, and men who have sex with men (MSM). For linkage to care, retention in care, and viral suppression, younger and non-Hispanic black people fared worse, whereas females and those enrolled in the Ryan White program fared better. For retention in care and viral suppression, Hispanic people, injection drug users, and East Tennessee residents fared worse than those in Memphis, whereas MSM fared better. Nashville residents fared worse in retention in care than Memphis residents. CONCLUSION: Tennessee's HIV continuum of care in 2013 showed progress toward 2015 goals. Future efforts to improve the HIV continuum of care should be directed toward vulnerable groups and regions, particularly young, non-Hispanic black, and Hispanic people; injection drug users; and residents of the East Tennessee and Nashville regions.


Assuntos
Antirretrovirais/uso terapêutico , Continuidade da Assistência ao Paciente/organização & administração , Infecções por HIV/tratamento farmacológico , Infecções por HIV/etnologia , Disparidades em Assistência à Saúde/etnologia , Adolescente , Adulto , Afro-Americanos , Fatores Etários , Antirretrovirais/administração & dosagem , Feminino , Infecções por HIV/diagnóstico , Acesso aos Serviços de Saúde/organização & administração , Hispano-Americanos , Humanos , Masculino , Pessoa de Meia-Idade , Fatores Sexuais , Comportamento Sexual , Abuso de Substâncias por Via Intravenosa/etnologia , Tennessee , Carga Viral , Adulto Jovem
16.
Curr Infect Dis Rep ; 17(1): 441, 2015 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-25416847

RESUMO

In September 2012, an unprecedented outbreak of fungal infections due to preservative-free, injectable methylprednisolone acetate (MPA) was identified. Exserohilum rostratum was quickly identified as the predominant organism involved in disease cases. Prior to this outbreak, little was known about the pathogenesis, treatment, and prognosis of infections due to this unusual brown-black mold. Almost 2 years after the onset of this outbreak, numerous epidemiologic and basic science studies have provided some guidance in understanding the epidemiology, clinical findings, diagnosis, and treatment of patients exposed to the contaminated medication. Additionally, this outbreak has directly led to the passage of legislation supporting increased regulation in the industry of pharmaceutical compounding. Many unanswered questions, particularly surrounding the long-term prognosis and outcomes for affected patients remain. However, it is clear that a strong relationship between clinicians caring for patients and public health as well as a rapid, effective public health response was critical in preventing additional cases of disease.

17.
J Clin Microbiol ; 53(3): 799-803, 2015 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-25540391

RESUMO

Prompt diagnosis and treatment of fungal meningitis are critical, but culture is insensitive. (1,3)-ß-d-Glucan (BDG) testing is FDA approved for serological diagnosis of invasive fungal disease; however, BDG testing is not approved for cerebrospinal fluid (CSF), and the appropriate cutoff value is unknown. We aimed to validate the diagnostic accuracy of CSF BDG measurements for fungal meningitis among patients exposed to contaminated methylprednisolone acetate (MPA). A retrospective observational study was conducted at St. Joseph Mercy Hospital and Vanderbilt University from November 2013 to February 2014. Patients were included if they had received a contaminated MPA injection. Cases were classified as probable or proven meningitis according to Centers for Disease Control and Prevention guidelines. CSF BDG testing was performed according to the package insert instructions for serum samples, and results were validated using Clinical and Laboratory Standards Institute procedures (MiraVista Diagnostics). Of 233 patients, 45 had meningitis (28 proven cases), 53 had spinal/paraspinal infections (19 proven cases), and 135 did not develop disease. Using the manufacturer's cutoff value (≥80 pg/ml), the sensitivity and specificity were 96% and 95%, respectively, for proven meningitis and 84% and 95% for probable or proven meningitis. Receiver operating characteristic analysis identified the optimal cutoff value for proven meningitis to be 66 pg/ml (sensitivity, 100%; specificity, 94%) and that for probable or proven meningitis to be 66 pg/ml (sensitivity, 91%; specificity, 92%). Our results suggest that CSF BDG measurements are highly sensitive and specific for the diagnosis of fungal meningitis associated with contaminated MPA injections. Further study on the utility of CSF BDG testing for other types of fungal meningitis is needed.


Assuntos
Líquido Cefalorraquidiano/química , Técnicas de Laboratório Clínico/métodos , Contaminação de Medicamentos , Meningite Fúngica/diagnóstico , beta-Glucanas/líquido cefalorraquidiano , Adulto , Idoso , Idoso de 80 Anos ou mais , Biomarcadores/líquido cefalorraquidiano , Feminino , Humanos , Injeções/efeitos adversos , Masculino , Metilprednisolona/administração & dosagem , Metilprednisolona/efeitos adversos , Pessoa de Meia-Idade , Curva ROC , Estudos Retrospectivos , Sensibilidade e Especificidade
20.
J Infect ; 67(5): 424-32, 2013 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-23845828

RESUMO

OBJECTIVES: To determine the rate of and risk factors for discontinuation of isoniazid due to adverse effects during the treatment of latent tuberculosis infection in a large, multi-site study. METHODS: The Tuberculosis Epidemiologic Studies Consortium (TBESC) conducted a prospective study from March 2007-September 2008 among adults initiating isoniazid for treatment of LTBI at 12 sites in the US and Canada. The relative risk for isoniazid discontinuation due to adverse effects was determined using negative binomial regression. Adjusted models were constructed using forward stepwise regression. RESULTS: Of 1306 persons initiating isoniazid, 617 (47.2%, 95% CI 44.5-50.0%) completed treatment and 196 (15.0%, 95% CI 13.1-17.1%) discontinued due to adverse effects. In multivariable analysis, female sex (RR 1.67, 95% CI 1.32-2.10, p < 0.001) and current alcohol use (RR 1.41, 95% CI 1.13-1.77, p = 0.003) were independently associated with isoniazid discontinuation due to adverse effects. CONCLUSIONS: The rate of discontinuation of isoniazid due to adverse effects was substantially higher than reported earlier. Women were at increased risk of discontinuing isoniazid due to adverse effects; close monitoring of women for adverse effects may be warranted. Current alcohol use was also associated with isoniazid discontinuation; counseling patients to abstain from alcohol could decrease discontinuation due to adverse effects.


Assuntos
Antituberculosos/efeitos adversos , Isoniazida/efeitos adversos , Tuberculose Latente/tratamento farmacológico , Adulto , Consumo de Bebidas Alcoólicas/epidemiologia , Antituberculosos/uso terapêutico , Canadá/epidemiologia , Feminino , Humanos , Isoniazida/uso terapêutico , Tuberculose Latente/epidemiologia , Masculino , Pessoa de Meia-Idade , Cooperação do Paciente/estatística & dados numéricos , Estudos Prospectivos , Análise de Regressão , Fatores Sexuais , Transtornos Relacionados ao Uso de Substâncias , Estados Unidos/epidemiologia
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