Table of Contents

• CD4 Lymphocyte Percentage Predicts Disease Progression in HIV-Infected Patients Initiating Highly Active Antiretroviral Therapy With CD4 Lymphocyte Counts >350 Lymphocytes/mm³
• Anal Intraepithelial Neoplasia in the Highly Active Antiretroviral Therapy Era Among HIV-Positive Men Who Have Sex With Men
• Hospital and Outpatient Health Services Utilization Among HIV-Infected Adults in Care (2000-2002)
• Safety and Tolerability of Nevirapine-Based Antiretroviral Therapy in HIV-Infected Patients Receiving Fluconazole for Cryptococcal Prophylaxis: A Case-Control Study

CD4 Lymphocyte Percentage Predicts Disease Progression in HIV-Infected Patients Initiating Highly Active Antiretroviral Therapy With CD4 Lymphocyte Counts >350 Lymphocytes/mm³

Hulgan T, Raffanti S, Kheshti A, et al.

Background: The optimal timing of highly active antiretroviral therapy (HAART) in human immunodeficiency virus (HIV)-infected patients with >200 absolute CD4 lymphocytes/mm³ is unknown. CD4 lymphocyte percentage could add prognostic information.

Methods: Persons who initiated HAART between January 1, 1998, and January 1, 2003, received >30 days of therapy, and had baseline CD4 lymphocyte data available were included in the study. The log-rank test for time to event and Cox proportional hazards models were used to determine predictors of a new acquired immunodeficiency syndrome (AIDS)-defining illness or death.

Results: A total of 788 patients met the inclusion criteria. At baseline, subjects had a median of 225 CD4 lymphocytes/mm³ and 17% CD4 lymphocytes. Subjects with <17% CD4 lymphocytes had earlier disease progression, compared with subjects with >17%, both in the entire cohort (P<0.0001) and of those subjects with >350 absolute CD4 lymphocytes/mm³ at baseline (P = 0.03). CD4 lymphocyte percentage <17% was the strongest predictor of disease progression among subjects in this latter group (hazard ratio [HR], 3.57; P = 0.045).

Conclusions: In this cohort, CD4 lymphocyte percentage predicted disease progression in HIV-infected subjects who initiated therapy with >350 CD4 lymphocytes/mm³. This information may help identify persons who will derive the greatest benefit from initiation of HAART. [J Infect Dis. 2005;192(6):950-957]

Anal Intraepithelial Neoplasia in the Highly Active Antiretroviral Therapy Era Among HIV-Positive Men Who Have Sex With Men

Palefsky JM, Holly EA, Efirdc JT, et al.

Objectives: The incidence of anal cancer among men who have sex with men (MSM) has continued to increase since the introduction of highly active antiretroviral therapy (HAART). The prevalence of the putative anal cancer precursor, anal intraepithelial neoplasia (AIN) was high among HIV-positive MSM prior to the availability of HAART, but little is known about AIN since HAART was introduced. We characterized the prevalence of AIN among HIV-positive MSM and examined the association between AIN and various factors including use of HAART.

Design/Methods: A baseline point-prevalence analysis in a prospective cohort study of AIN was performed at a university-based research clinic. A total of 357 HIV-positive MSM with no history of anal cancer completed a questionnaire detailing behaviors and medical history, anal cytology and human papillomavirus (HPV) testing, and high-resolution anoscopy with biopsy for detection of AIN.

Results: Eighty-one percent of participants with available CD4 cell counts at baseline had AIN of any grade; 52% had AIN 2 or 3; and 95% had anal HPV infection. In multivariate analysis, detection of six or more HPV types (odds ratio [OR], 36; 95% confidence interval [CI], 7.4-171) and use of HAART (OR, 10; 95% CI, 2.6-38) were associated with AIN after adjustment for length of time participants were HIV-positive, CD4 count and HIV viral load.

Conclusions: The prevalence of AIN has remained high among HIV-positive MSM after the introduction of HAART. Our data indicate that HAART is not associated with a reduced prevalence of AIN, and support measures to prevent anal cancer among HIV-positive MSM whether or not they are using HAART. [AIDS. 2005;19(13):1407-1414.]

Hospital and Outpatient Health Services Utilization Among HIV-Infected Adults in Care (2000-2002)

Fleishman JA, Gebo KA, Reilly ED, et al for the HIV Research Network.

Background: Rapid changes in HIV epidemiology and antiretroviral therapy may have resulted in recent changes in patterns of health care utilization.

Objective: The objective of this study was to examine sociodemographic and clinical correlates of inpatient and outpatient HIV-related health service utilization in a multistate sample of patients with HIV.

Design: Demographic, clinical, and resource utilization data were collected from medical records for 2000, 2001, and 2002.

Setting: This study was conducted at 11 US HIV primary and specialty care sites in different geographic regions.

Patients: In each year, HIV-positive patients with at least one CD4 count and any use of inpatient, outpatient, or emergency room services. Sample sizes were 13,392 in 2000, 15,211 in 2001, and 14,403 in 2002.

Main Outcome Measures: Main outcome measures were number of hospital admissions, total days in hospital, and number of outpatient clinic/office visits per year. Inpatient and outpatient costs were estimated by applying unit costs to numbers of inpatient days and outpatient visits.

Results: Mean numbers of admissions per person per year decreased from 2000 (0.40) to 2002 (0.35), but this difference was not significant in multivariate analyses. Hospitalization rates were significantly higher among patients with greater immunosuppression, women, blacks, patients who acquired HIV through drug use, those 50 years of age and over, and those with Medicaid or Medicare. Mean annual outpatient visits decreased significantly between 2000 and 2002, from 6.06 to 5.66 visits per person per year. Whites, Hispanics, those 30 years of age and over, those on highly active antiretroviral therapy (HAART), and those with Medicaid or Medicare had significantly higher outpatient utilization. Inpatient costs per patient per month (PPPM) were estimated to be US$514 in 2000, US$472 in 2001, and US$424 in 2002; outpatient costs PPPM were estimated at US$108 in 2000, US$100 in 2001, and US$101 in 2002.

Conclusion: Changes in utilization over this three-year period, although statistically significant in some cases, were not substantial. Hospitalization rates remain relatively high among minority or disadvantaged groups, suggesting persistent disparities in care. Combined inpatient and outpatient costs for patients on HAART were not significantly lower than for patients not on HAART. [Med Care. 2005;43(Suppl 9):S40-S52.]

Safety and Tolerability of Nevirapine-Based Antiretroviral Therapy in HIV-Infected Patients Receiving Fluconazole for Cryptococcal Prophylaxis: A Case-Control Study

Manosuthi W, Chumpathat N, Chaovavanich A, Sungkanuparph S.

Background: To compare the adverse events after initiation of nevirapine (NVP)-based antiretroviral therapy (ART) among HIV-infected patients who did not receive fluconazole (group A), received fluconazole 400 mg/week (group B), and received fluconazole 200 mg/day (group C).

Methods: A retrospective cohort study was conducted among HIV-infected patients who began NVP-based ART between December 2003 and September 2004. Patients were followed up for six months. Clinical hepatitis, elevated aspartate aminotransferase (AST) and alanine aminotransferase (ALT) (> 3 times from baseline), and skin rashes were studied.

Results: There were 686 patients; 225, 392, and 69 patients in groups A, B, and C, respectively. Baseline characteristics including age, previous opportunistic infections, use of antituberculous drugs, and baseline aminotransferase levels among the three groups were similar. Group C had a higher proportion of men (P = 0.016). Baseline median (interquartile range [IQR]) CD4 counts were 85 (21-159), 18 (7-48), and 16 (5-35) cells/mm³ in groups A, B, and C, respectively (P < 0.001). Two of 225 (0.9%), four of 392 (1.0%), and zero of 69 (0%) patients in groups A, B, and C developed clinical hepatitis (P = 0.705). There was no significant difference in elevated AST or ALT among the three groups (P > 0.05). By logistic regression, receiving fluconazole was not predictive of clinical hepatitis, elevated aminotransferase, or skin rashes. At six months after initiating NVP, 174 (77.3%) patients in group A, 309 (78.8%) patients in group B, and 58 (84.1%) patients in group C remained on NVP.

Conclusion: Initiation of NVP-based ART among Thais with advanced HIV disease receiving fluconazole is safe and well tolerated. Nevirapine should not be contraindicated for patients receiving fluconazole for treatment or prophylaxis of cryptococcosis. [BMC Infect Dis. 2005;5(1):67.]