AIDS Patient Care and STDs

Treatment with highly active antiretroviral therapy (HAART) decreases morbidity and mortality for persons with human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) and reduces costs of care. Yet many patients for whom HAART is indicated do not receive it. This study investigated the reasons why certain patients of a community health center with HIV/AIDS did not receive HAART between 1997 and 1998. Medical record reviews were performed to determine which patients for whom HAART was indicated (according to United States Public Health Service guidelines) were not prescribed HAART. Chart reviews and patient interviews were conducted to determine why they did not receive HAART. Of the 88 patients eligible for HAART, 60 (69%) had it prescribed in 1997–1998. Of the remaining 28 patients, 3 did not receive HAART because their provider never discussed it with them. For 6 patients (21%), the provider discussed HAART but did not recommend it; 16 patients (57%) declined HAART although their provider recommended it, and 3 (11%) accepted their provider's recommendation but never started HAART. Patients' most common reasons for refusing HAART were not being ready for strict adherence to a complex regimen (7/16) and fear of side effects (6/16). Other reasons included active drug use, religious beliefs, homelessness, confidentiality concerns, depression, and feeling well without HAART. Providers did not recommend HAART because of active drug use (4/6), lack of engagement with care (2/6) as well as homelessness, depression, and the perception that the patient was doing well without HAART. Providers should be trained to offer all patients the opportunity to develop a plan to address barriers to adherence and the support needed to implement it. Resources should also target the treatment of substance abuse and mental illness to improve the usage of HAART.

In this observational single-center cohort study outside the clinical trial setting, outcome and predictors of virologic failure of highly active antiretroviral therapy (HAART) containing a protease inhibitor were evaluated in human immunodeficiency (HIV)-infected persons. The study population consisted of 807 protease inhibitor-naive HIV-seropositive patients who initiated antiretroviral therapy with reverse transcriptase inhibitors and protease inhibitors (indinavir, nelfinavir, ritonavir) between January 1997 and January 1999. Demographic variable, plasma HIV-1 RNA levels, CD4⁺ T-cell count, adverse drug reactions, and adherence to HAART were assessed. Virologic treatment response was defined as a decrease in plasma HIV-1 RNA load from baseline to below 500 copies per milliliter after 12 months of therapy. Levels of HIV-1 RNA were undetectable in 43% of patients at 12 months. Factors associated with failure to suppress viral load included age 40 years or younger, baseline CD4⁺ T cell count less than 200 × 10⁶ per liter baseline viral load greater than 4.3 log₁₀ per milliliter, and non-adherence to HAART. After adjustment by logistic regression, non-adherence was the only statistically significant variable associated with virologic failure (odds ratio 0.38, 95% confidence interval 0.21 to 0.67). Unselected patients in whom protease inhibitor is started in a usual clinical setting achieve viral suppression less frequently than do patients in controlled clinical trials. Failure to adherence to HAART was the strongest predictor of virologic failure.

To explore women's experiences and beliefs concerning zidovudine (AZT) therapy during pregnancy, short-answer and open-ended questions were asked of 322 human immunodeficiency virus (HIV)-infected women at increased risk for pregnancy. Specifically, we examined what women believed they had been told concerning AZT therapy during pregnancy by health care professionals and peers, experiences with taking AZT, how effective they believed AZT therapy to be, and if they would take AZT if they became pregnant. Women in the study were predominately African American (88%), single (79%), with a mean age of 32 years, and had annual incomes less than $10,000 (64%). Although 81.4% of the women had been told to take antiretrovirals, only 69.1% of the women were actually taking HIV-related medicines. Almost three-fourths of the women (70.8%) reported being told that taking AZT during pregnancy would reduce perinatal transmission. Women reported the most frequent reason for their stopping AZT was its side effects. When women who were not presently taking AZT were asked what would make them consider taking it, they most frequently said they would begin AZT if their health deteriorated or based on the advice of health care professionals. A small group of women said nothing would make them take AZT-type medications. More than one-half of the women said they felt AZT was effective in preventing perinatal HIV transmission. However, almost 20% of the women reported believing that their health care provider would not be positive about their taking AZT during pregnancy. Significant relationships were found between intent to take AZT if becoming pregnant and specific AZT-related beliefs and experiences.

Although the health-related quality of life (HRQOL) and social support (SS) after the acknowledgement of human immunodeficiency virus (HIV)-seropositive results are important issues in HIV acquired immune deficiency syndrome (AIDS) counseling, they have not yet been fully studied. The investigators examined the healthy HIV patients's HRQOL and SS in a 24-week prospective study design. The HRQOL and SS of a participant were assessed by using Quality of Life Index (QL-Index) and Social Relationship Scale (SRS), respectively. The QL-Index, SRS quality (SRS-Q), and SRS extent of network (SRS-EN) scores were rated at baseline (week 0), week 12, and week 24. The significant differences of QL-Index, SRS-Q, and SRS-EN scores obtained at three points of time were initially analyzed by using a repeated measure multivariate analysis of variance (MANOVA). For those significantly different scores, a paired t test was applied to determine the significant difference of a pair of scores. Sixty-nine healthy individuals who had never had HIV tests participated in this study. Of these, 37 were HIV-seropositive. The HRQOL and SS of 37, 30, and 27 HIV-seropositive participants were evaluated at week 0, at week 12, and week 24, respectively. No significant difference was found among QL-Index scores and among SRS-Q scores obtained at those three points of time. However, SRS-EN scores obtained at week 24 were significantly higher than those obtained at week 0 and at week 12. In conclusion, an HIV-seropositive result by itself does not have much impact on a healthy HIV patient's HRQOL and SS. In contrast, his or her SS seems to be widened over time.

In addition to developing immunosuppression, opportunistic infections, and malignancies, patients infected with human immunodeficiency virus (HIV) also develop many hematologic disorders. Although cytopenias including thrombocytopenia, anemia, and leukopenia, and bone marrow dysplasia are the most common hematologic complications encountered in such patients, hemostatic abnormalities that predispose patients to thromboembolism have also been recognized. Anemia in HIV patients can be multifactorial but an increased incidence of autoimmune hemolytic anemia has been manifested by the increased incidence of positive Coombs' test reported in patients with acquired immune deficiency syndrome (AIDS). Overt hemolysis is a rare complication. This review article discusses the etiology, pathophysiology, clinical features, diagnosis, treatment, and complications of autoimmune hemolytic anemia (AIHA) associated with HIV infection.