Randomized Controlled Trial: 4 Month versus 6 Month Monitoring of HIV-infected Patients on Highly Active Antiretroviral Therapy.

As HIV treatment becomes more widely available and efficacious, and persons with HIV live longer, considerations for the financial and healthcare impact are of important. The best interval for routine HIV monitoring has been identified as area in which gaps in knowledge exist. The goal of this study is to determine the impact of changing scheduled follow up care for persons with HIV from a 4 to 6 months interval. HIV infected adults with a CD4 count ≥250 cells/µl, and an undetectable HIV viral load (VL) by an ultrasensitive assay for at least 1 year were randomized to routine HIV care at either a 4 or 6 months interval. Subjects were monitored for virological failure, adherence and quality of life (QOL). 142 subjects were enrolled and completed study protocol. Two subjects in the 6 months arm developed virological failure, p value = 0.5. There was no difference in adherence, or QOL scores. Subjects in the 4 months arm had higher rates of HIV visits (8.5/100 vs. 5.2/100 person months, p = 0.01) and non-HIV related visits (9.4/100 vs. 6.0/100 person months, p = 0.01) and were more likely to change antiretroviral regimen (34.8 vs. 15.8 %, p = 0.01). Despite strict inclusion criteria in this relatively short follow up time, 2/142 (1.4 %) subjects developed virological failure and many more had transient detectable VL. While not statistically significant a larger study with longer follow up is needed.

Vertebral osteomyelitis: retrospective review of 11 years of experience.

INTRODUCTION: Infectious vertebral osteomyelitis (VO) is a significant source of morbidity that can lead to chronic sequelae. The objectives of this study were to describe the clinical presentations and assess the outcomes of VO. METHODS: A retrospective review of cases of VO admitted to an inpatient service between 1 January 2000 and 31 March 2012 was carried out. Cases had evidence of VO by clinical syndrome, imaging, histopathology, and/or microbiology. Outcomes assessed were implantation of prosthetic material for stabilization, hospital readmission for management of VO, repeat surgical intervention, and additional or prolonged courses of antibiotics. RESULTS: Of 117 VO cases, a causative organism was identified in the majority (88.0%). Staphylococcus aureus was the most common organism isolated, followed by Streptococcus species. The most common infection site was the lumbar spine (55.5%). Surgical intervention was required in 81.2% of cases. Infections involving the lumbar vertebrae were associated with a higher risk of all 4 outcomes. Individuals with methicillin-resistant S. aureus infection were more likely to require a readmission for management of VO (odds ratio (OR) 3.94, 95% confidence interval (CI) 1.25-12.42). Individuals with lumbar infections were more likely to require additional antibiotics (OR 4.08, 95% CI 1.34-12.40) and more likely to require readmission (OR 8.29, 95% CI 1.84-37.33) for management of VO. An early infectious disease consultation was associated with a decreased risk for additional antibiotics (OR 0.30, 95% CI 0.11-0.83). CONCLUSIONS: VO was frequently caused by S. aureus or Streptococcus species. Most cases required surgical intervention. An early infectious disease consult ensured a more appropriate antibiotic course.

The reality of homeless mobility and implications for improving care.

Homeless persons are perceived as a highly mobile population, and have high rates of co-morbid conditions, including mental health and substance use issues. This study sought to determine the characteristics of the mobility and reported health conditions of homeless persons. The sample for this cross sectional study (n = 674) accounted for 88 % of the homeless population in a medium sized southern city in the United States. Participants were recruited from a homeless shelter operating during the winter season. Homeless persons were less mobile than the general state population (46.11 % were born in-state vs. 40.7 % of the general population) and less transient than the general state population (78 % reported an in-state zip code for the last permanent residence). 31.9 % reported a disabling condition of a serious and long term nature. These findings challenge the concept that homeless persons are primarily a mobile population. Furthermore, homeless persons in this sample were more likely to remain in the state where they lived after becoming homeless. Thus, provider perceptions that homeless persons would not benefit from referral to a regular source of outpatient care may be misinformed. As homeless persons often seek care in emergency departments for conditions that could be addressed through outpatient care, if a medical care system implemented standard practices specifically for homeless patients, this could decrease recidivism. Such interventions represent significant opportunities to reduce costs, conserve resources, and improve care through policy modification that ensures a focus on a successful, active linkage to outpatient care and programs specific to the homeless population.

Cause of death in HIV-infected patients in South Carolina (2005-2013).

The life span of persons with HIV has been greatly extended over the past 30 years due to novel therapies. In the developed world and urban settings, this results in a lifespan rivaling the lifespan of a person without HIV. A retrospective study was conducted on 459 patients of an urban, academic medical center who died between 2005 and 2013 in a medium-sized US city. Using the established Cause of Death Project (CoDe) protocol, we measured multiple factors including comorbidities, risk behaviours, contributing and underlying causes of death. This study is one of the few US-based studies using this validated protocol. Among the deaths, 25.9% were sudden and 15.2% were unexpected. Almost one-fifth were related to AIDS-related infections; 47.5% related to non-AIDS causes; with the remainder unknown. Statistically significant increases in CD4 counts and decreasing viral loads were observed over the study period. There were no statistically significant differences observed by HIV risk behaviour, race, gender, age at death, or on antiretrovirals at death. In support of the existing literature, improved HIV management appears to reduce the AIDS-related attributable death among patients observed in this study.

Differences in risk behaviors, care utilization, and comorbidities in homeless persons based on HIV status.

This cross-sectional pilot project measured differences by HIV status in chronic health conditions, primary care and emergency department use, and high-risk behaviors of homeless persons through self-report. Using selective random sampling, 244 individuals were recruited from a homeless shelter. The reported HIV prevalence was 6.56% (n = 16), with the odds of HIV higher in persons reporting crack cocaine use. HIV-infected persons were more likely to report a source of regular medical care and less likely to use the emergency department than uninfected persons. Validation of findings through exploration of HIV and health care access in homeless persons is needed to confirm that HIV-infected homeless persons are more likely to have primary care. Distinctions between primary care and specialty HIV care also need to be explored in this context. If findings are consistent, providers who care for the homeless could learn more effective ways to engage homeless patients.