SUMMARY The availability of an increasing number of antiretroviral agents and the rapid evolution of new information has introduced extraordinary complexity into the treatment of HIV-infected persons. In 1996, the Department of Health and Human Services and the Henry J. Kaiser Family Foundation convened the Panel on Clinical Practices for the Treatment of HIV to develop guidelines for the clinical management of HIV-infected adults and adolescents. This report recommends that care should be supervised by an expert, and makes recommendations for laboratory monitoring including plasma HIV RNA, CD4 cell counts and HIV drug resistance testing. The report also provides guidelines for antiretroviral therapy, including when to start treatment, what drugs to initiate, when to change therapy, and therapeutic options when changing therapy. Special considerations are provided for adolescents and pregnant women. As with treatment of other chronic conditions, therapeutic decisions require a mutual understanding between the patient and the health care provider regarding the benefits and risks of treatment. Antiretroviral regimens are complex, have major side effects, pose difficulty with adherence, and carry serious potential consequences from the development of viral resistance due to non-adherence to the drug regimen or suboptimal levels of antiretroviral agents. Patient education and involvement in therapeutic

/pdf/guidelines-for-the-use-of-antiretroviral-agents-in-hiv-3wuv1pwax4.pdf

Guidelines for the use of antiretroviral agents in HIV-infected adults and adolescents

Objectives. We aimed to describe socioeconomic disparities in the United States across multiple health indicators and socioeconomic groups.Methods. Using recent national data on 5 child (infant mortality, health status, activity limitation, healthy eating, sedentary adolescents) and 6 adult (life expectancy, health status, activity limitation, heart disease, diabetes, obesity) health indicators, we examined indicator rates across multiple income or education categories, overall and within racial/ethnic groups.Results. Those with the lowest income and who were least educated were consistently least healthy, but for most indicators, even groups with intermediate income and education levels were less healthy than the wealthiest and most educated. Gradient patterns were seen often among non-Hispanic Blacks and Whites but less consistently among Hispanics.Conclusions. Health in the United States is often, though not invariably, patterned strongly along both socioeconomic and racial/ethnic lines, suggesting lin...

https://ajph.aphapublications.org/doi/pdf/10.2105/AJPH.2009.166082

Socioeconomic Disparities in Health in the United States: What the Patterns Tell Us

Background: There have been no previous nationally representative estimates of the prevalence of mental disorders and drug use among adults receiving care for human immunodeficiency virus (HIV) disease in the United States. It is also not known which clinical and sociodemographic factors are associated with these disorders. Subjects and Methods: We enrolled a nationally representative probability sample of 2864 adults receiving care for HIV in the United States in 1996. Participants were administered a brief structured psychiatric instrument that screened for psychiatric disorders (major depression, dysthymia, generalized anxiety disorders, and panic attacks) and drug use during the previous 12 months. Sociodemographic and clinical factors associated with screening positive for any psychiatric disorder and drug dependence were examined in multivariate logistic regression analyses. Results: Nearly half of the sample screened positive for a psychiatric disorder, nearly 40% reported using an illicit drug other than marijuana, and more than 12% screened positive for drug dependence during the previous 12 months. Factors independently associated with screening positive for a psychiatric disorder included number of HIV-related symptoms, illicit drug use, drug dependence, heavy alcohol use, and being unemployed or disabled. Factors independently associated with screening positive for drug dependence included having many HIV-related symptoms, being younger, being heterosexual, having frequent heavy alcohol use, and screening positive for a psychiatric disorder. Conclusions: Many people infected with HIV may also have psychiatric and/or drug dependence disorders. Clinicians may need to actively identify those at risk and work with policymakers to ensure the availability of appropriate care for these treatable disorders.

https://jamanetwork.com/journals/jamapsychiatry/articlepdf/205826/yoa9450.pdf

Psychiatric Disorders and Drug Use Among Human Immunodeficiency Virus–Infected Adults in the United States

Background Among persons in North America who are newly infected with the human immunodeficiency virus (HIV), the prevalence of transmitted resistance to antiretroviral drugs has been estimated at 1 to 11 percent. Methods We performed a retrospective analysis of susceptibility to antiretroviral drugs before treatment and drug-resistance mutations in HIV in plasma samples from 377 subjects with primary HIV infection who had not yet received treatment and who were identified between May 1995 and June 2000 in 10 North American cities. Responses to treatment could be evaluated in 202 subjects. Results Over the five-year period, the frequency of transmitted drug resistance increased significantly. The frequency of high-level resistance to one or more drugs (indicated by a value of more than 10 for the ratio of the 50 percent inhibitory concentration [IC50] for the subject's virus to the IC50 for a drug-sensitive reference virus) increased from 3.4 percent during the period from 1995 to 1998 to 12.4 percent dur...

https://www.nejm.org/doi/pdf/10.1056/NEJMoa013552

Antiretroviral-Drug Resistance among Patients Recently Infected with HIV

Racialized science seeks to explain human population differences in health, intelligence, education, and wealth as the consequence of immutable, biologically based differences between "racial" groups. Recent advances in the sequencing of the human genome and in an understanding of biological correlates of behavior have fueled racialized science, despite evidence that racial groups are not genetically discrete, reliably measured, or scientifically meaningful. Yet even these counterarguments often fail to take into account the origin and history of the idea of race. This article reviews the origins of the concept of race, placing the contemporary discussion of racial differences in an anthropological and historical context.

/pdf/race-as-biology-is-fiction-racism-as-a-social-problem-is-25dlybdszx.pdf

Race as biology is fiction, racism as a social problem is real: Anthropological and historical perspectives on the social construction of race.

ContextStudies of selected populations suggest that not all
persons infected with human immunodeficiency virus (HIV) receive
adequate care.ObjectiveTo examine variations in the care received by a national
sample representative of the adult US population infected with HIV.DesignCohort study that consisted of 3 interviews from January
1996 to January 1998 conducted by the HIV Cost and Services Utilization
Consortium.Patients and SettingMultistage probability sample of 2864
respondents (68% of those targeted for sampling), who represent the
231,400 persons at least 18 years old, with known HIV infection
receiving medical care in the 48 contiguous United States in early 1996
in facilities other than emergency departments, the military, or
prisons. The first follow-up consisted of 2466 respondents and the
second had 2267 (65% of all surviving sampled subjects).Main Outcome MeasuresService utilization (<2 ambulatory visits,
at least 1 emergency department visit that did not lead to
hospitalization, at least 1 hospitalization) and medication utilization
(receipt of antiretroviral therapy and prophylaxis against
Pneumocystis carinii pneumonia).ResultsInadequate HIV care was commonly reported at the time of
interviews conducted from early 1996 to early 1997 but declined to
varying degrees by late 1997. Twenty-three percent of patients
initially and 15% of patients subsequently had emergency department
visits that did not lead to hospitalization, 30% initially and 26%
subsequently of those who had CD4 cell counts below
0.20,×109/L did not receive P
carinii pneumonia prophylaxis, and 41% initially and 15%
subsequently of those who had CD4 cell counts below
0.50×109/L did not receive antiretroviral
therapy (protease inhibitor or nonnucleoside reverse transcriptase
inhibitor). Inferior patterns of care were seen for many of these
measures in blacks and Latinos compared with whites, the uninsured and
Medicaid-insured compared with the privately insured, women compared
with men, and other risk and/or exposure groups compared with men who
had sex with men even after CD4 cell count adjustment. With
multivariate adjustment, many differences remained statistically
significant. Even by early 1998, fewer blacks, women, and uninsured and
Medicaid-insured persons had started taking antiretroviral medication
(CD4 cell count adjusted P values <.001 to <.005).ConclusionsAccess to care improved from 1996 to 1998 but
remained suboptimal. Blacks, Latinos, women, the uninsured, and
Medicaid-insured all had less desirable patterns of care. Strategies to
ensure optimal care for patients with HIV requires identifying the
causes of deficiency and addressing these important shortcomings in
care.

https://jamanetwork.com/journals/jama/articlepdf/190531/JOC81503.pdf

Variations in the Care of HIV-Infected Adults in the United States: Results From the HIV Cost and Services Utilization Study

Background and Methods In order to elucidate the medical care of patients with human immunodeficiency virus (HIV) infection in the United States, we randomly sampled HIV-infected adults receiving medical care in the contiguous United States at a facility other than a military, prison, or emergency department facility during the first two months of 1996. We interviewed 76 percent of 4042 patients selected from among the patients receiving care from 145 providers in 28 metropolitan areas and 51 providers in 25 rural areas. Results During the first two months of 1996, an estimated 231,400 HIV-infected adults (95 percent confidence interval, 162,800 to 300,000) received care. Fifty-nine percent had the acquired immunodeficiency syndrome according to the case definition of the Centers for Disease Control and Prevention, and 91 percent had CD4+ cell counts of less than 500 per cubic millimeter. Eleven percent were 50 years of age or older, 23 percent were women, 33 percent were black, and 49 percent were men wh...

The Care of HIV-Infected Adults in the United States

Objective To examine the trade-offs inherent in selecting a sample design for a national study of care for an uncommon disease, and the adaptations, opportunities and costs associated with the choice of national probability sampling in a study of HIV/AIDS. Setting A consortium of public and private funders, research organizations, community advocates, and local providers assembled to design and execute the study. Design Data collected by providers or collected for administrative purposes are limited by selectivity and concerns about validity. In studies based on convenience sampling, generalizability is uncertain. Multistage probability sampling through households may not produce sufficient cases of diseases that are not highly prevalent. In such cases, an attractive alternative design is multistage probability sampling through sites of care, in which all persons in the reference population have some chance of random selection through their medical providers, and in which included subjects are selected with known probability. DATA COLLECTION AND PRINCIPAL FINDINGS: Multistage national probability sampling through providers supplies uniquely valuable information, but will not represent populations not receiving medical care and may not provide sufficient cases in subpopulations of interest. Factors contributing to the substantial cost of such a design include the need to develop a sampling frame, the problems associated with recruitment of providers and subjects through medical providers, the need for buy-in from persons affected by the disease and their medical practitioners, as well as the need for a high participation rate. Broad representation from the national community of scholars with relevant expertise is desirable. Special problems are associated with organization of the research effort, with instrument development, and with data analysis and dissemination in such a consortium. Conclusions Multistage probability sampling through providers can provide unbiased, nationally representative data on persons receiving regular medical care for uncommon diseases and can improve our ability to accurately study care and its outcomes for diseases such as HIV/AIDS. However, substantial costs and special circumstances are associated with the implementation of such efforts.

National probability samples in studies of low-prevalence diseases. Part I: Perspectives and lessons from the HIV cost and services utilization study.

Diet, exercise, smoking, and substance use patterns affect the course of illness and quality of life for people with HIV. In interviews with a national probability sample of 2,864 persons receiving HIV care, it was found that most had made health-promoting changes in one or more of these behaviors since diagnosis. Many reported increased physical activity (43%) and improved diet (59%). Forty-nine percent of cigarette smokers quit or cut down; 80% of substance users did so. Desire for involvement in one's HIV care and information seeking-positive coping were the most consistent correlates of change. Other correlates varied by health practice but included health status, emotional well-being, demographics, and attitudes toward other aspects of HIV care. Most people with HIV improve their health behavior following diagnosis, but more might be helped to do so by targeting these behaviors in future interventions.

J W Senterfitt

Papers

Variations in the Care of HIV-Infected Adults in the United States: Results From the HIV Cost and Services Utilization Study

The Care of HIV-Infected Adults in the United States

National probability samples in studies of low-prevalence diseases. Part I: Perspectives and lessons from the HIV cost and services utilization study.

Changes in health-promoting behavior following diagnosis with HIV: prevalence and correlates in a national probability sample.