Factors associated with mortality in patients with drug-susceptible pulmonary tuberculosis.

BACKGROUND: Tuberculosis is a leading cause of death worldwide, yet the determinants of death are not well understood. We sought to determine risk factors for mortality during treatment of drug-susceptible pulmonary tuberculosis under program settings. METHODS: Retrospective chart review of patients with drug-susceptible tuberculosis reported to the San Francisco Tuberculosis Control Program from 1990-2001. RESULTS: Of 565 patients meeting eligibility criteria, 37 (6.6%) died during the study period. Of 37 deaths, 12 (32.4%) had tuberculosis listed as a contributing factor. In multivariate analysis controlling for follow-up time, four characteristics were independently associated with mortality: HIV co-infection (HR = 2.57, p = 0.02), older age at tuberculosis diagnosis (HR = 1.52 per 10 years, p = 0.001); initial sputum smear positive for acid fast bacilli (HR = 3.07, p = 0.004); and experiencing an interruption in tuberculosis therapy (HR = 3.15, p = 0.002). The association between treatment interruption and risk of death was due to non-adherence during the intensive phase of treatment (HR = 3.20, p = 0.001). The median duration of treatment interruption did not differ significantly in either intensive or continuation phases between those who died and survived (23 versus 18 days, and 37 versus 29 days, respectively). No deaths were directly attributed to adverse drug reactions. CONCLUSIONS: In addition to advanced age, HIV and characteristics of advanced tuberculosis, experiencing an interruption in anti-tuberculosis therapy, primarily due to non-adherence, was also independently associated with increased risk of death. Improving adherence early during treatment for tuberculosis may both improve tuberculosis outcomes as well as decrease mortality.

Detailed analysis of the radiographic presentation of Mycobacterium kansasii lung disease in patients with HIV infection.

BACKGROUND: Published criteria for the diagnosis of Mycobacterium kansasii lung disease require the presence of clinical symptoms, positive microbiologic results, and radiographic abnormalities. In patients with HIV infection, the radiographic findings of M kansasii lung disease are not well described. METHODS: Medical records and chest radiographs of all patients with HIV infection and at least one respiratory specimen culture positive for M kansasii at San Francisco General Hospital between December 1989 and July 2002 were reviewed. RESULTS: Chest radiographic results were abnormal in 75 of 83 patients (90%) included in the study. Radiographic abnormalities were diverse, with consolidation (66%) and nodules (42%) as the most frequent findings. The mid or lower lung zones were involved in 89% of patients. The pattern of radiographic abnormalities did not differ based on acid-fast bacilli smear status, the presence or absence of coexisting pulmonary infections, or CD4+ T-lymphocyte count. In multivariate Cox regression analysis, cavitation was the only radiographic abnormality independently associated with mortality (hazard ratio, 4.8; 95% confidence interval, 1.2 to 19.6). CONCLUSION: Patients with HIV infection and M kansasii lung disease present with diverse radiographic patterns, most commonly consolidation and nodules predominantly located in the mid and lower lung zones. This finding is in contrast to the upper-lobe cavitary presentation described in patients without HIV infection. Although rare, the presence of cavitary disease in patients with HIV infection and M kansasii independently predicts worse outcome. The diversity in the radiographic presentation of M kansasii lung disease implies that clinicians should obtain sputum mycobacterial culture samples from any patient with HIV infection and an abnormal chest radiograph finding.

Awareness of Kaposi's sarcoma-associated herpesvirus among men who have sex with men.

BACKGROUND: Despite burgeoning scientific knowledge about Kaposi's sarcoma-associated herpesvirus (KSHV), the etiologic agent of Kaposi's sarcoma (KS), little is known about awareness of this virus in the general community. This is particularly the case for men who have sex with men (MSM), the group at greatest risk for infection. METHODS: The California Health Interview Survey was a random digit- dial survey of over 50,000 households. Men aged 18 to 64 years who self-identified as gay or bisexual were subsequently recontacted for a follow-up study of HIV-related knowledge and behavior in which they were asked if they had heard of KS and to describe the cause of KS. RESULTS: Of 398 MSM interviewed, 73.0% (95% CI 65.0-79.7) had heard of KS. However, only 6.4% (95% CI 4.4-9.2) of participants correctly identified that KS is caused by KSHV or a virus other than HIV. Postgraduate education, urban residence, and concurrent HIV infection were all independently associated with greater awareness of the viral origin of KS. CONCLUSION: Awareness of KSHV is very low, overall, among MSM and only somewhat higher, but still unacceptably low, among HIV-infected MSM. Significant efforts are needed to increase awareness of KSHV as a sexually transmitted infection in this population.

Changes in prevalence of HIV infection and sexual risk behavior in men who have sex with men in San Francisco: 1997 2002.

OBJECTIVES: We assessed differences in HIV prevalence and sexual risk behavior among men who have sex with men (MSM) between 1997 and 2002 in San Francisco. METHODS: We used 2 population-based random-digit-dial telephone surveys of MSM households in San Francisco in 1997 (n=915) and 2002 (n=879). RESULTS: Estimated HIV prevalence increased from 19.6% in 1997 to 26.8% in 2002. Measures of sexual risk also increased. Unprotected anal intercourse with a partner of different or unknown HIV serostatus increased from 9.3% to 14.6%. Mean number of male partners increased from 10.7 to 13.8. The largest reported increase was 18.9% to 26.8% for "serosorting," or choosing unprotected anal intercourse partners believed to have the same HIV serostatus as oneself. Men aged 30 to 50 reported the largest increase in unprotected anal intercourse, whereas men aged 18 to 29 reported the largest increase in serosorting. Changes in the age distribution did not explain the increase in risky behavior. CONCLUSIONS: Both HIV prevalence and sexual risk increased substantially among MSM in San Francisco between 1997 and 2002. Serosorting is being adopted more frequently than condom use by young MSM, but its effectiveness as a harm reduction strategy is not known.

Knowledge of sexual partner's HIV serostatus and serosorting practices in a California population-based sample of men who have sex with men.

OBJECTIVES: To describe knowledge of primary and secondary sexual partner's HIV serostatus and sexual practices, including serosorting, among men who have sex with men (MSM) living in California. METHODS: Men who self-identified as gay/bisexual in the 2001 California Health Interview Survey, a statewide biennial random-digit-dial survey interviewing more than 50,000 adults on a variety of health topics, were recontacted in 2002 and interviewed by telephone about injection drug use, their own and partner's HIV serostatus, and sexual risk behaviors. RESULTS: Among 220 men who reported a primary partner, 86% [95% confidence interval (CI): 77-92] knew their primary partner's serostatus; 62% (95% CI, 52-70) of the 250 men who reported a secondary partner knew their most recent secondary partner's HIV serostatus. Knowledge of one's most recent secondary partner's HIV serostatus was inversely related to history of injecting recreational drugs (odds ratio, 0.22; P < 0.01), and reporting a primary partner in the past year (odds ratio, 0.37; P < 0.05). Two-fifths (41%) of HIV-positive men and three-fifths (62%) of HIV-negative men engaged in serosorting (serocordant unprotected anal intercourse) with their primary partners, whereas 33% HIV-positive men and 20% HIV-negative men did so with their most recent secondary partners. CONCLUSIONS: This population-based survey documented the extent to which MSM know their partners' serostatus and practice serosorting behaviors. The findings emphasize the need for studies to report serocordant and serodiscordant unprotected anal intercourse separately, as the former presents significant lower risk of HIV transmission.

The impact of Medicaid managed care on hospitalizations for ambulatory care sensitive conditions.

OBJECTIVE: To determine whether Medicaid managed care is associated with lower hospitalization rates for ambulatory care sensitive conditions than Medicaid fee-for-service. We also explored whether there was a differential effect of Medicaid managed care by patient's race or ethnicity on the hospitalization rates for ambulatory care sensitive conditions. DATA SOURCES/STUDY SETTING: Electronic hospital discharge abstracts for all California temporary assistance to needy families (TANF)-eligible Medicaid beneficiaries less than age 65 who were admitted to acute care hospitals in California between 1994 and 1999. STUDY DESIGN: We performed a cross-sectional comparison of average monthly rates of admission for ambulatory care-sensitive conditions among TANF-eligible Medicaid beneficiaries in fee-for-service, voluntary managed care, and mandatory managed care. DATA COLLECTION/EXTRACTION METHODS: We calculated monthly rates of ambulatory care-sensitive condition admission rates by counting admissions for specified conditions in hospital discharge files and dividing the monthly count of admissions by the size of the at-risk population derived from a separate monthly Medicaid eligibility file. We used multivariate Poisson regression to model monthly hospital admission rates for ambulatory care-sensitive conditions as a function of the Medicaid delivery model controlling for admission month, admission year, patient age, sex, race/ethnicity, and county of residence. PRINCIPAL FINDINGS: The adjusted average monthly hospitalization rate for ambulatory care-sensitive conditions per 10,000 was 9.36 in fee-for-service, 6.40 in mandatory managed care, and 5.25 in voluntary managed care (p<.0001 for all pairwise comparisons). The difference in hospitalization rates for ambulatory care sensitive conditions in Medicaid fee-for-service versus managed care was significantly larger for patients from minority groups than for whites. CONCLUSIONS: Selection bias in voluntary Medicaid managed care programs exaggerates the differences between managed care and fee-for-service, but the 33 percent lower rate of hospitalizations for ambulatory care sensitive conditions found in mandatory managed care compared with fee-for-service suggests that Medicaid managed care is associated with a large reduction in hospital utilization, which likely reflects health benefits. The greater effect of Medicaid managed care for minority compared with white beneficiaries is consistent with other findings that suggest that managed care is associated with improvements in access to ambulatory care for those patients who have traditionally faced the greatest barriers to health care.

Decline in HIV infectivity following the introduction of highly active antiretroviral therapy.

OBJECTIVE: Little is known about the degree to which widespread use of antiretroviral therapy in a community reduces uninfected individuals' risk of acquiring HIV. We estimated the degree to which the probability of HIV infection from an infected partner (the infectivity) declined following the introduction of highly active antiretroviral therapy (HAART) in San Francisco. DESIGN: Homosexual men from the San Francisco Young Men's Health Study, who were initially uninfected with HIV, were asked about sexual practices, and tested for HIV antibodies at each of four follow-up visits during a 6-year period spanning the advent of widespread use of HAART (1994-1999). METHODS: We estimated the infectivity of HIV (per-partnership probability of transmission from an infected partner) using a probabilistic risk model based on observed incident infections and self-reported sexual risk behavior, and tested the hypothesis that infectivity was the same before and after HAART was introduced. RESULTS: A total of 534 homosexual men were evaluated. Decreasing trends in HIV seroincidence were observed despite increases in reported number of unprotected receptive anal intercourse partners. Conservatively assuming a constant prevalence of HIV infection between 1994 and 1999, HIV infectivity decreased from 0.120 prior to widespread use of HAART, to 0.048 after the widespread use of HAART- a decline of 60% (P=0.028). CONCLUSIONS: Use of HAART by infected persons in a community appears to reduce their infectiousness and therefore may provide an important HIV prevention tool.

Risk of HIV infection attributable to oral sex among men who have sex with men and in the population of men who have sex with men.

We examined HIV infection and estimated the population-attributable risk percentage (PAR%) for HIV associated fellatio among men who have sex with other men (MSM). Among 239 MSM who practised exclusively fellatio in the past 6 months, 50% had three partners, 98% unprotected; and 28% had an HIV-positive partner; no HIV was detected. PAR%, based on the number of fellatio partners, ranges from 0.10% for one partner to 0.31% for three partners. The risk of HIV attributable to fellatio is extremely low.

Association between diabetes mellitus and tuberculosis in United States-born and foreign-born populations in San Francisco.

SETTING: The impact of diabetes on tuberculosis in United States and foreign-born populations in San Francisco has not been studied. OBJECTIVE: To determine the characteristics, prevalence and temporal trends of diabetes in US and foreign-born persons attending the San Francisco Tuberculosis Clinic. DESIGN: We analyzed data from individuals seeking medical attention at the San Francisco Tuberculosis Clinic. We included patients with diagnosis of tuberculosis, latent infection, or not infected with Mycobacterium tuberculosis. We assessed the temporal trend and the characteristics of individuals with and without diabetes. RESULT: Between 2005 and 2012, there were 4371 (19.0%) individuals without evidence of tuberculosis infection, 17,856 (77.6%) with latent tuberculosis, and 791 (3.4%) with tuberculosis. 66% were born in the United States, China, Mexico, and the Philippines. The prevalence of diabetes was the highest among individuals with tuberculosis and increased during the study period. Patients with tuberculosis and diabetes were more likely to be male, older than 45 years and born in the Philippines. There was a disproportionate association of TB and DM relative to LTBI and DM among Filipinos in individuals older than 45 years old. CONCLUSIONS: Our data suggest that Filipinos older than 45 years old are more likely to have tuberculosis probably due to a higher prevalence of diabetes. In San Francisco, tuberculosis-screening programs in individuals with diabetes and latent tuberculosis may be beneficial in patients older than 45 years old especially from the Philippines.

Use of saliva as a lubricant in anal sexual practices among homosexual men.

OBJECTIVES: Compared with other sexually active adults, men who have sex with men (MSM) are more frequently infected with several pathogens including cytomegalovirus, hepatitis B virus, and Kaposi sarcoma-associated herpesvirus. Because one common element between these organisms is their presence in saliva, we evaluated saliva exposure among MSM in a heretofore relatively unrecognized route-via use of saliva as a lubricant in anal sex. METHODS: MSM in a San Francisco population-based cohort were interviewed regarding use of saliva by the insertive partner as a lubricant in various anal sexual practices. RESULTS: Among 283 MSM, 87% used saliva as a lubricant in insertive or receptive penile-anal intercourse or fingering/fisting at some point during their lifetime; 31%-47% did so, depending upon the act, in the prior 6 months. Saliva use as a lubricant was more common among younger men and among HIV-infected men when with HIV-infected partners. Even among MSM following safe sex guidelines by avoiding unprotected penile-anal intercourse, 26% had anal exposure to saliva via use as a lubricant. CONCLUSIONS: Among MSM, use of saliva as a lubricant is a common, but not ubiquitous, practice in anal sex. The findings provide the rationale for formal investigation of whether saliva use in this way contributes to transmission of saliva-borne pathogens in MSM.

Treatment outcomes of patients with HIV and tuberculosis.

RATIONALE: The optimal length of tuberculosis treatment in patients coinfected with HIV is unknown. OBJECTIVES: To evaluate treatment outcomes for HIV-infected patients stratified by duration of rifamycin-based tuberculosis therapy. METHODS: We retrospectively reviewed data on all patients with tuberculosis reported to the San Francisco Tuberculosis Control Program from 1990 through 2001. Patients were followed for up to 12 months after treatment completion. MEASUREMENTS AND MAIN RESULTS: Of 700 patients, 264 (38%) were HIV infected, 315 (45%) were not infected, and 121 (17%) were not tested. Mean duration of treatment was extended to 10.2 months for HIV-infected patients versus 8.4 months for uninfected/unknown patients (p < 0.001). Seventeen percent of the HIV-infected and 37% of the HIV uninfected/unknown patients received 6 months of rifamycin-based therapy. The relapse rate among HIV-infected was 9.3 per 100 person-years versus 1.0 in HIV-uninfected/unknown patients (p < 0.001). HIV-infected individuals who received a standard 6-month rifamycin-based regimen were more likely to relapse than those treated longer (adjusted hazard ratio, 4.33; p = 0.02). HIV-infected individuals who received intermittent therapy were also more likely to relapse than those treated on daily basis (adjusted hazard ratio, 4.12; p = 0.04). The use of highly active antiretroviral therapy was associated with more rapid conversion of smears and cultures and with improved survival. CONCLUSIONS: HIV-infected patients who received a 6-month rifamycin-based course of tuberculosis treatment or who received intermittent therapy had a higher relapse rate than HIV-infected subjects who received longer therapy or daily therapy, respectively. Standard 6-month therapy may be insufficient to prevent relapse in patients with HIV.

HIV prevalence and sexual risk behaviors among men who have sex with men: results from a statewide population-based survey in California.

OBJECTIVES: To investigate HIV prevalence, sexual risk behaviors, and HIV testing among men who have sex with men (MSM) between 18 and 64 years old living in California. DESIGN: Cross-sectional study of a statewide population-based sample of MSM. METHODS: Using data from the 2001 California Health Interview Survey (CHIS 2001), 398 men who self-identified as gay or bisexual were recontacted and interviewed by telephone for a follow-up study in 2002. Study participants were interviewed regarding their demographic characteristics and sexual behavior, HIV testing history, and HIV infection status. Those who self-reported as HIV-negative or of unknown status were offered an HIV test using a home urine specimen collection kit. RESULTS: HIV prevalence among MSM in California was 19.1% (95% confidence interval [CI]: 12.8% to 25.3%) with higher rates seen among the following subgroups: high school or less education (40.4%), annual income less than dollar 20,000 (35.0%), or history of ever injecting recreational drugs (40.3%). Young age and Hispanic or African-American race/ethnicity were associated with higher proportions of risky sexual behavior and lower HIV testing rates. CONCLUSIONS: HIV prevalence among MSM living in California continues to be high across the whole state, and population-based studies are needed periodically to complement findings from surveys using other sampling designs.

The effect of venue sampling on estimates of HIV prevalence and sexual risk behaviors in men who have sex with men.

OBJECTIVE: The objective of this study was to investigate differences in HIV prevalence and sexual risk behaviors among men who have sex with men (MSM) according to their gay venue visit patterns. METHODS: In a cross-sectional survey, a population-based sample of men aged 18 to 64 years who self-identified as gay or bisexual were interviewed by telephone regarding their sexual behaviors, HIV serostatus, and gay venue visit patterns. RESULTS: A total of 398 men were recruited for the study. The results showed that frequent gay venue visitors were more likely to engage in high-risk sexual behaviors. Among gay venue attendees who visited different types of gay venues, men who visited sex clubs/bathhouses reported the highest rates of 5 or more male sexual partners and unprotected anal intercourse (UAI) with secondary partners (62.6% and 34.6%, respectively), gay bar/club attendees and cruisers reported higher rates of having sex with women (8.5% and 14.8%, respectively), and circuit party attendees reported the highest HIV prevalence (40.4%) and serodiscordant UAI (30.2%). CONCLUSIONS: MSM who visited different types of gay venues and with varied visit frequency showed marked differences in sexual risk behaviors, and the differences suggest the importance of weighting procedure to obtain unbiased estimates in venue-based studies.

Evaluation of the Center for Disease Control and Prevention's HIV behavioral surveillance of men who have sex with men: sampling issues.

BACKGROUND: The Centers for Disease Control and Prevention is embarking on a program of biannual venue-based time-space sampling surveys to monitor prevalence and incidence of HIV among men who have sex with men (MSM). GOAL: We examine the efficacy of the suggested methodology in terms of population coverage, sample period, range of venues, and representativeness. STUDY: The 2002 Urban Men's Health Study (N = 879) is a telephone interview of a household probability sample of adult MSM living in San Francisco. RESULTS: A 6-month bar/club sample would capture 79% of the adult MSM population and yield an accurate estimate of HIV prevalence. Using a longer sample period or sampling other less-frequented venues yields marginal improvement. Risk behavior, when broadly defined, is overestimated. CONCLUSIONS: The National HIV Behavioral Surveillance of MSM protocol may be satisfactory for sampling urban MSM within defined limits, but could be conducted at significantly less cost by reducing the types of venues and fielding time. However, bias in the venue sample with respect to risk behavior and other key correlates argues for validity checks based on household probability samples conducted at infrequent intervals.

Tuberculosis treatment outcomes: directly observed therapy compared with self-administered therapy.

Effective treatment of tuberculosis requires adherence to a minimum of 6 months treatment with multiple drugs. To improve adherence and cure rates, directly observed therapy is recommended for the treatment of pulmonary tuberculosis. We compared treatment outcomes among all culture-positive patients treated for active pulmonary tuberculosis (n = 372) in San Francisco County, California from 1998 through 2000. Patients treated by directly observed therapy at the start of therapy (n = 149) had a significantly higher cure rate compared with patients treated by self-administered therapy (n = 223) (the sum of bacteriologic cure and completion of treatment, 97.8% versus 88.6%, p < 0.002), and decreased tuberculosis-related mortality (0% vs. 5.5%, p = 0.002). Rates of treatment failure, relapse, and acquired drug resistance were similar between the two groups. Forty-four percent of patients who received self-administered therapy had risk factors for nonadherence and should have been assigned to directly observed therapy. We conclude that treatment plans that emphasize directly observed therapy from the start of therapy have the greatest success in improving tuberculosis treatment outcomes.

Trends in causes of death among persons with acquired immunodeficiency syndrome in the era of highly active antiretroviral therapy, San Francisco, 1994-1998.

To understand recent temporal trends in acquired immunodeficiency syndrome (AIDS) mortality in the era of highly active antiretroviral therapy (HAART), trends in causes of death among persons with AIDS in San Francisco who died between 1994 and 1998 were analyzed. Among 5234 deaths, the mortality rate for human immunodeficiency virus (HIV)-related or AIDS-related deaths declined after 1995 (P<.01), whereas the mortality rate for non-HIV- or non-AIDS-related deaths remained stable. The proportion of deaths of persons with AIDS associated with septicemia, non-AIDS-defining malignancy, chronic liver disease, viral hepatitis, overdose, obstructive lung disease, coronary artery disease, and pancreatitis increased (P<.05). The standardized mortality ratio was high for these causes in both pre- and post-HAART periods, except for pancreatitis, a possible complication of HAART, which demonstrated an increasing standardized mortality ratio trend after 1996. With increasing AIDS survival, prevention of chronic diseases, assessment of long-term toxicity from HAART, and surveillance for additional causes of mortality will become increasingly important.

Prevalence of Kaposi sarcoma-associated herpesvirus infection in homosexual men at beginning of and during the HIV epidemic.

CONTEXT: Some studies have inferred that an epidemic of Kaposi sarcoma-associated herpesvirus (KSHV) infection in homosexual men in the United States occurred concurrently with that of human immunodeficiency virus (HIV), but there have been no direct measurements of KSHV prevalence at the beginning of the HIV epidemic. OBJECTIVES: To determine the prevalence of KSHV infection in homosexual men in San Francisco, Calif, at the beginning of the HIV epidemic in 1978 and 1979 and to examine changes in prevalence of KSHV at time points from 1978 through 1996 in light of changes in sexual behavior. DESIGN, SETTING, AND PARTICIPANTS: Analysis of a clinic-based sample (n = 398) derived from the San Francisco City Clinic Cohort (ages 18-66 years) (n = 2666 for analyses herein) and from population-based samples from the San Francisco Men's Health Study (MHS) (ages 25-54 years) (n = 825 and 252) and the San Francisco Young Men's Health Study (YMHS) (ages 18-29 years) (n = 428-976, and 557); behavioral studies were longitudinal and KSHV prevalence studies were cross-sectional. MAIN OUTCOME MEASURES: Antibodies against KSHV and HIV; sexual behaviors. RESULTS: The prevalence of KSHV infection in 1978 and 1979 was 26.5% of 235 (a random sample) overall (weighted for HIV infection) vs 6.9% (128/1842) for HIV in the San Francisco City Clinic Cohort sample. The prevalence of KSHV infection remained essentially unchanged between an MHS sample of 252 in 1984 and 1985 (29.6%) and a YMHS sample of 557 in 1995 and 1996 (26.4%), while HIV prevalence dropped from 49.5% of 825 in 1984 and 1985 (MHS) to 17.6% of 428 in 1992 and 1993 (YMHS). The proportion of men practicing unprotected receptive anal intercourse with 1 or more partners declined from 54% to 11% during the 1984 through 1993 period (MHS) with similar though slightly higher values in the YMHS in 1992 and 1993; whereas for unprotected oral intercourse it ranged between 60% and 90% in the 1984 through 1996 period (MHS and YMHS). CONCLUSIONS: Infection with KSHV was already highly prevalent in homosexual men when the HIV epidemic began in San Francisco, and its prevalence has been maintained at a nearly constant level. Any declines in the incidence of Kaposi sarcoma do not appear to be caused by a decline in KSHV transmission.