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A collection of interview-based articles by leading experts in infectious diseases.

News By Topic:

Infectious Diseases

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Table of Contents 14

Lessons Learned in Implementing HIV Testing in EDs — Christian Arbelaez, MD, MPH and Rochelle P. Walensky, MD, MPH

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Preventing Clostridium Difficile Infections — Erik R. Dubberke, MD

112 Closing Gaps in Hepatitis B Screening — Danny Chu, MD

114 Extending Survival for HIV-Infected Patients — Elena Losina, PhD

A Message From the Editor We at Physician’s Weekly are excited to present you with an eBook dedicated to infectious diseases. In recent months, our publication has featured a variety of news items in this field, focusing on clinical and evidencebased research. The content in these articles relies on the expertise of our contributing physician authors. We anticipate that Physician’s Weekly will continue to feature news in this field of medicine in the coming months. We hope that you find this information useful in your practice. Please let us know your thoughts by contacting us at editor@physweekly.com. Sincerely,

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December 14, 2009 • Issue No. 47 Click here to view this article online.

Lessons Learned in

Implementing HIV Testing in EDs

Although there is currently no clear guidance on appropriate implementation of HIV testing in EDs, new data provide insights on key strategies that may enable more hospitals to accomplish this feat effectively.

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bout 20% of the estimated 1 million people living with HIV infection in the United States are unaware of their diagnosis. In 2006, as a response to these statistics, the CDC recommended that HIV testing be offered to adults aged 13 to 64 in all healthcare settings, including EDs. “The main shift was to go from risk-based HIV testing to routine HIV testing in the ED. The goal was to make HIV screening as routine as standard blood tests,” says Christian Arbelaez, MD, MPH. “Prior to the guidelines, there were, and still are, many missed opportunities to identify HIV-infected patients

Christian Arbelaez, MD, MPH Assistant Residency Director Department of Emergency Medicine Brigham and Women’s Hospital Assistant Professor Harvard Medical School

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who had seen providers in primary care and acute care settings because they didn’t have the classic risk factors.” The American College of Emergency Physicians responded to the CDC recommendations with an HIV policy statement, which noted that screening must be practical, feasible, not interfere with the primary acute care mission, be based on local prevalence, and be integrated with local healthcare systems. Since then, numerous approaches to HIV testing in the ED have already been implemented as

Also Contributing to This Article: Rochelle P. Walensky, MD, MPH Division of Infectious Disease Brigham and Women’s Hospital Massachusetts General Hospital Associate Professor of Medicine Harvard Medical School


a public health screening service; such programs have had varying degrees of success. “Unfortunately,” says Dr. Arbelaez, “there have been long-standing barriers associated with HIV screening in the ED setting. Specific guidance for EDs on how to successfully and efficiently implement routine HIV screening will facilitate adoption into clinical practice.”

New Testing Model Assessed Dr. Arbelaez, Rochelle P. Walensky, MD, MPH, and colleagues designed and implemented an HIV testing program, initiated in 2006. Findings were published online in the September 3, 2009 International Journal of Emergency Medicine. The study group identified several components to creating a successful HIV testing program in the ED. The framework included identification of a champion; completion of a needs assessment; development of a comprehensive team; selection of an appropriate HIV test; establishment of proper protocols and quality assur-

ance measures; and provision of education and training for providers. “Our objective was to describe the protocol development and implementation strategies that worked for us so that other EDs embarking on such programs may benefit from what we learned,” Dr. Arbelaez explains.

Collaboration is Critical When initiating a program for rapid HIV screening in EDs, Dr. Arbelaez says that a team leader must be evident from the time the program is first launched (Table 1). “The success of any ED-based HIV testing program relies heavily on the investment of designated champions who will lead efforts within the ED community and hospital.” Champions need to consider staff engagement, test selection, protocol development, education and training of personnel, and linkage to care. Dr. Walensky adds that “developing an interdisciplinary team of supportive clinical and administrative staff is a critical step in achiev-

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ing success with rapid HIV screening programs in EDs. This includes involvement with ED per­ sonnel, infectious disease personnel, and laboratory services personnel.” In selecting the most appropriate HIV test to use, several factors should be taken into consideration, including the plans/locale for test development, current hospital standards, and costs and available resources. Space available to conduct point-of-care testing, test performance, and turn-around time for results are other important considerations. “Rapid HIV tests have facilitated routine testing; but even among them, there are those that can streamline the process to best suit your intended patient flow,” Dr. Arbelaez says. Properly educating and training personnel and other staff on HIV are paramount to successfully integrating a screening program in EDs. Dr. Arbelaez says that buy-in is best achieved if all staff understand the benefits of routine HIV testing (Table 2). “Previous research suggests that ED providers generally feel uninformed about HIV testing,” he says. “They also report that they would welcome more information and resources on the topic. Strategies for education and

Table 1

Another important consideration when designing and implementing HIV screening programs in EDs is spatial constraints. “Many patient care rooms are simply not private,” explains Dr. Arbelaez. “HIV testing is a sensitive issue that should be conducted privately, regardless of the results. Patients who consent for testing may also have questions about whether or not participating in HIV screening will affect their care or if their providers will be notified about their participation. Those establishing the program must consider if, whether, and how the results of an EDbased test will be documented in the medical record; patients will ask.”

Planning Next Steps The development of a framework on appropriate protocols for reactive HIV screening test results is critical (Table 3). “It’s important to remember that positive test results often lead to anxiety for patients and staff,” says Dr. Arbelaez. “Specific plans should be in place to address and alleviate such anxieties for

Getting Started

• Designate champion(s) who will lead efforts for HIV testing within the ED community and hospital. - Champion’s capacity for leadership, action, and consensus within all aspects of the ED staff will portend the program’s success. • Perform needs assessments within the community and the patient population. - Determine HIV prevalence within the hospital catchment area. - Establish that there is an unmet need for HIV testing services. • Understand referral base for patients who might be identified within ED testing programs. - Determine wait times for newly diagnosed patient appointment. - Determine if clinical HIV outpatient programs have the capacity to longitudinally care for new patients. • Establish if funding support is available and draft budget proposals. - Consider necessary resources for personnel, HIV test kits, training sessions, and confirmatory laboratory expenses. • Establish a comprehensive team to ensure necessary support for success. Source: Adapted from: Arbelaez C, et al. Intl J Emerg Med. 2009 Sept 3 [Epub ahead of print].

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training to supplement communication efforts may include training sessions for protocols and procedures, HIV-related resources via local testing sites or websites, a program website, bulletin boards, walking rounds, and ‘frequently asked question’ handouts.”

Table 2

Education and Training

• Obtain “buy-in” by informing staff about the benefits of routine HIV testing programs. • Establish team members and learning about such programs (including testing protocols and patient resources). • As an incentive, consider awarding Continuing Education Units for nurses who attend the program. • Training sessions may include: - Basic facts about HIV transmission. - Local incidence/prevalence estimates. - State-based ethical and legal issues surrounding HIV testing. - HIV-related resources. • Consider websites, bulletin boards, and “frequently asked question” handouts to supplement communication with staff. • Consider offering courses to certify HIV counselors with training in the process of offering, consenting, testing, and counseling patients prior to HIV testing. Source: Adapted from: Arbelaez C, et al. Intl J Emerg Med. 2009 Sept 3 [Epub ahead of print].


Table 3

When Rapid HIV Tests Return Positive

A prescriptive plan regarding what to do with positive rapid HIV test results may allay anxiety among testers, staff, and patients. A “Reactive (Positive) Result Packet” (including mock scripts) may help standardize processes and minimize confusion when delivering results. Contents of such a packet include:

1. “How to deliver a reactive result” script 2. The rapid HIV test manufacturer package insert 3. General information sheet on HIV infection 4. Confirmatory test protocol • Pre-printed laboratory requisition slips

5. Linkage-to-care protocol • Person in charge of scheduling appointments • Parking arrangements • Maps to the location of the appointment • Interpreter contact information Source: Adapted from: Arbelaez C, et al. Intl J Emerg Med. 2009 Sept 3 [Epub ahead of print].

everyone.” The study team created a ‘Reactive (Positive) Result Packet,’ which included mock scripts and other tools to help personnel when delivering results. It also provides resources for follow-up and linkage to care. “Tools like this may help standardize processes, minimize confusion, and simply streamline the process for patients.” Dr. Arbelaez says.

In settings where rapid tests are used, HIV-preliminary reactive results should be confirmed with a Western Blot, CD4 panel, and an HIV viral load. Once confirmed, resources should be devoted to link newly diagnosed HIV-infected patients to longterm HIV care, says Dr. Arbelaez. “Prescriptive plans should be in place so that ED staff can manage patients appropriately. These plans may include scheduling appointments, arranging transportation and parking, directions or maps to clinics, and having an interpreter available when necessary. Appointments should be made as quickly as possible after the availability of confirmatory results. If appointments aren’t kept, staff should be designated to make repeated attempts to discreetly reach patients in person, by phone, and/or by mail.” He adds that if patients leave without test results, there should be protocols in place to ensure that results are still received quickly and discretely to ensure that follow-up care is pursued. With the appropriate infrastructure and with longitudinal and financial support, Dr. Arbelaez says that routine HIV testing in the ED is feasible. “Our hope is that components of our program will serve as a model and preliminary guidance for other EDs so that we can reduce the burden of HIV in the U.S.”

Christian Arbelaez, MD, MPH, and Rochelle P. Walensky, MD, MPH, have indicated to Physician’s Weekly that they have received grants/research aid from the NIH and have no other financial interests to report.

References Arbelaez C, Block B, Losina E, et al. Rapid HIV testing program implementation: lessons from the emergency department. Intl J Emerg Med. 2009 Sept 3 [Epub ahead of print]. Available at: http://www.springerlink.com/content/uh413r6w380l476q/ World Health Organization. Priority interventions HIV/AIDS prevention, treatment and care in the health sector. February 2009. Available at: http://www.who.int/hiv/pub/priority_interventions_web.pdf USPSTF Screening for HIV recommendation statement. April 2007. Available at: http://www.ahrq.gov/clinic/uspstf/uspshivi.htm CDC. Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings. MMWR. 2006;55:RR-14. Millen JC, Arbelaez C, Walensky RP. Implications and impact of the new US Centers for Disease Control and Prevention HIV testing guidelines. Curr Infect Dis Rep. 2008; 2:157-163. Borg KT. To test or not to test? HIV, emergency departments, and the new Centers for Disease Control and Prevention guidelines. Ann Emerg Med. 2007;49:573-574. Brown J, Shesser R, Simon G, et al. Routine HIV screening in the emergency department using the new US Centers for Disease Control and Prevention guidelines: Results from a high-prevalence area. J Acquir Immune Defic Syndr. 2007;46:395-401. McKenna M. HIV testing: Should the emergency department take part? Ann Emerg Med. 2007;49:190-192. Walensky RP, Arbelaez C, Reichmann WM, et al. Revising expectations from rapid HIV tests in the emergency department. Ann Intern Med. 2008;149:153-160.

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January 11, 2010 • Issue No. 2 Click here to view this article online.

Erik R. Dubberke, MD Assistant Professor, Medicine Division of Infectious Diseases Washington University School of Medicine, St. Louis

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Preventing

Clostridium Difficile

Infections

New guidance from infectious disease experts aim to help clinicians prevent common healthcare-associated infections. Practical recommendations are provided to assist acute care hospitals in preventing Clostridium difficile infections.

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ccording to published data, Clostridium difficile infection (CDI) now rivals MRSA as the most common organism to cause healthcare-associated infections (HAIs) in the United States. The pro­portion of hospital discharges in which patients received a diagnostic code for CDI more than doubled between 2000 and 2003, and rates continued to increase in 2004 and 2005. “In addition to increased frequency of CDI, current research also shows that these infections are increasing in severity,” says Erik R. Dubberke, MD. CDI has been associated with increased lengths of hospital stay, higher costs, and greater morbidity and mortality. According to study data, CDI has been shown to increase lengths of hospital stay by about 3 days. Costs have also been significant; the total U.S. hospital costs for CDI management have been estimated at about $3.2 billion per year. The infection has been associated with attributable mortality rates of 16.7% at 1 year.

New Guidance In 2008, a task force to create a concise compendium of recommendations for the prevention of common HAIs was appointed by the Society for Healthcare Epidemiology of America and the Infectious Diseases Society of America. Recommendations were published in the October 2008 supplement to Infection Control and Hospital Epidemiology and are available at www.preventingHAIs.com. The document is designed to help hospitals focus and prioritize their efforts to implement evidence-based practices for the prevention of HAIs, including CDI. According to the compendium recommendations, fluoroquinolones had been infrequently associated with CDI. However, new research has found that these agents are one of the primary predisposing antimicrobials associated with the infection. “Most antibiotics have been associated with CDI,” explains Dr. Dubberke. “It’s important to consider patient characteristics that may be risk factors for CDI. The visit www.physweekly.com

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detection of CDI can be challenging for clinicians.” The recommendations note that the most commonly used methods for identifying the infection are positive results from diarrhea stool tests for toxigenic C difficile or its toxins (Table 1).

Prevention Strategies There are two primary strategies to preventing CDIs that have been outlined by previously published guidelines. The first is to implement strategies that reduce the risk of CDI if the organism is encountered by patients. In these circumstances, clinicians should restrict the use of antimicrobial therapies and implement stewardship guidelines. The second involves using strategies that prevent patients from being exposed to C difficile (Table 2). “Understanding the importance of disinfection and barrier methods is critical to preventing CDI,” Dr. Dubberke says. “One area of frequent confusion is the preferred method of hand hygiene after caring for patients with CDI. Although alcohol does not kill C difficile spores, no studies have identified an increase in CDI with alcohol-based hand hygiene products. In addition, alcohol-based products are associated with better compliance and are superior at preventing the spread of other organisms.”

Table 1

Identifying Patients With CDI

Positive results of diarrhea stool tests for toxigenic C difficile or its toxins are the most common methods used to identify patients with CDI.

Table 2

General Strategies to Prevent CDI

As per previously published guidelines, general strategies to prevent CDI include: Methods of reducing the risk of CDI if the organism is encountered by the patient. • F ollow antimicrobial usage restriction and stewardship guidelines. Methods of preventing the patient from being exposed to C difficile (disinfection and barrier methods). • A void the use of electronic thermometers; the handles become contaminated with C difficile. • U se dedicated patient care items and equipment; if items must be shared, clean and disinfect the equipment between patients. • U se full barrier precautions (gowns and gloves) for contact with patients with CDI and for contact with their body substances and environment (contact precautions). • P lace patients with CDI in private rooms, if available; give isolation preference to patients with fecal incontinence if room availability is limited.

- A positive result of a test for toxigenic C difficile and/or its toxins in a patient with diarrhea is con­sidered to be diagnostic for CDI.

• P erform meticulous hand hygiene based on CDC or World Health Organization guidelines before and after entering the room of a patient with CDI, with soap and water or an alcohol-based hand hygiene product (in routine settings or settings of endem­i­city). Perform hand hygiene with soap and water preferentially, instead of alcohol hand hygiene products, after caring for a patient with CDI in outbreak settings or settings of hyperendemicity. Ensure that proper hand hygiene techniques are used when hand washing with soap and water is employed.

- Some centers permit C difficile testing of non-diarrhea stools. In such cases, review of patient records is required to ensure that the patient has symptoms consistent with CDI.

• P erform environmental decontamination of rooms housing patients with CDI, using sodium hypochlorite (household bleach) diluted 1:10 with water, in an outbreak setting or setting of hyper­endemicity.

• Positive results of diarrhea stool tests should auto­matically be sent to infection prevention and control professionals and to clinicians caring for the patient. • Only diarrheal stools should be tested for C difficile or its toxins.

• A minority of patients have CDI diagnosed by visualization of pseudo-membranes by endoscopy and/or histopathologic analysis, without positive stool test results. Abbreviation: CDI, Clostridium difficile infection. Source: Adapted from: Dubberke ER, et al. Infect Control Hosp Epidemiol. 2008;29(Suppl 1):S81-S92.

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Besides hand hygiene, Dr. Dubberke says that physicians managing CDI must wear gloves and gowns prior to entering patients’ rooms. “Hands are just as likely to be contaminated with C difficile even if there is no direct patient contact,” he adds. “However, proper hand hygiene is still important even after glove removal. Furthermore, hospitals and their staff must monitor housekeeping protocols. Diluted bleach appears to be effective only in areas experiencing a CDI outbreak. The key is for institutions to establish processes and protocols that everyone on staff will practice routinely.”

• E ducate healthcare personnel and hospital administration about the clinical features, transmission, and epidemiology of CDI. Abbreviation: CDI, Clostridium difficile infection. Source: Adapted from: Dubberke ER, et al. Infect Control Hosp Epidemiol. 2008;29(Suppl 1):S81-S92.


Understanding the importance of disinfection and barrier methods is critical to preventing CDI. — Erik R. Dubberke, MD The compendium recommendations also describe other important principles that clinicians should be aware of when caring for patients with CDI. For example, testing for C difficile should only be performed on unformed diarrhea stools; toxin testing of formed stool is strongly discouraged. Prophylactic antimicrobial CDI therapy should not be given to patients at high risk for CDI. Additionally, attempts to decolonize asymptomatic C difficile carriers should not be carried out, and antimicrobial therapy is not effective for decolonization. The recommen­ dations also note that repeated testing for C difficileshould not be performed if patients have had a stool sample test positive for the organism unless symptoms resolved with treatment and then returned after treatment.

Get on Board An important step to preventing CDI is to educate healthcare personnel and hospital administration about the clinical features, transmission, and epidemiology of CDI. “Process measures are a core component for hospitals to be accredited,” says Dr. Dubberke. “Administration must be on board and provide the resources needed for an effective antimicrobial stewardship and other infectious disease and safety services. There may be added costs to consider, but preventing even a handful of C difficile cases can more than make up for the costs for doing surveillance and initiating protocols.”

Erik R. Dubberke, MD, has indicated to Physician’s Weekly that he has worked as a consultant for Becton-Dickinson, Salix, and Merck.

References To access more efforts from the Compendium of Strategies to Prevent Healthcare-Associated Infections, go to www.preventingHAIs.com Dubberke ER, Gerding DN, Classen D, et al. Strategies to prevent clostridium difficile infections in acute care hospitals. Infect Control Hosp Epidemiol. 2008;29(Suppl 1):S81-S92. Available at: http://www.journals.uchicago.edu/doi/full/10.1086/591065. McDonald LC, Owings M, Jernigan DB. Clostridium difficile infection in patients discharged from US short-stay hospitals, 1996-2003. Emerg Infect Dis. 2006;12:409-415. Kuijper EJ, Coignard B, Tull P. Emergence of Clostridium difficile-associated disease in North America and Europe. Clin Microbiol Infect. 2006;12(Suppl 6):2-18. Muto CA, Pokrywka M, Shutt K, et al. A large outbreak of Clostridium difficile-associated disease with an unexpected proportion of deaths and colectomies at a teaching hospital following increased fluoroquinolone use. Infect Control Hosp Epidemiol. 2005;26:273-280. Dubberke ER, Reske KA, Olsen MA, McDonald LC, Fraser VJ. Short and long term attributable cost of Clostridium difficile–associated disease in non-surgical patients. Clin Infect Dis. 2008;46:497-504. McDonald LC, Coignard B, Dubberke E, Song X, Horan T, Kutty PK. Recommendations for surveillance of Clostridium difficile–associated disease. Infect Control Hosp Epidemiol. 2007;28:140-145. Fowler S, Webber A, Cooper BS, et al. Successful use of feedback to improve antibiotic prescribing and reduce Clostridium difficile infection: a controlled interrupted time series. J Antimicrob Chemother. 2007;59:990-995. Sehulster L, Chinn RY. Guidelines for environmental infection control in health-care facilities. Recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee (HICPAC). MMWR Recomm Rep. 2003;52:1-42. McDonald LC. Confronting Clostridium difficile in inpatient healthcare facilities. Clin Infect Dis. 2007;45:1274-1276.

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October 19, 2009 • Issue No. 39 Click here to view this article online. Click here to listen to the podcast. (04:23)

Closing Gaps in

Hepatitis B

Screening C

hronic hepatitis B, which is caused by infection with the hepatitis B virus (HBV), disproportionately affects people in the United States who are of Asian descent. An estimated 2 million people in America are living with the disease, and Asian Americans account for over half of this prevalence. First-generation Asian Americans are at the highest risk. It’s estimated that as many as one in 10 foreign-born Asians are living with chronic hepatitis B, a rate more than 20 times greater than that of the general population. This discrepancy reflects the high incidence of HBV infection in several Asian countries, where immunization against the disease is not yet standard practice. As a result of chronic HBV infection, Asian Americans are at greater risk of developing liver cancer, and are 2.4 times more likely than Caucasians to die from liver cancer.

New Survey on Screening Practices Despite clear evidence of the heavy burden of hepatitis B on Asians, a recent survey my colleagues and I presented at the 2009 International Symposium on Viral Hepatitis and Liver Disease showed that many physicians serving the Asian-American community fail to routinely screen for HBV. The study—which was based on data from 233 Asian-American physicians in the New York, Los Angeles, San Francisco, Houston, and Chicago metropolitan areas—demonstrated that only 50% of doctors reported routinely screening all of their Asian-American patients for HBV. In addition, 40% of doctors surveyed said 12

they had screened no more than a quarter of AsianAmerican patients. The most frequently-cited reason for not offering screening was the perception that patients were not at risk for the virus. These low levels of HBV screening in the AsianAmerican community suggest that an alarming number of infected individuals are going undiagnosed and untreated. According to some estimates, up to two-thirds of Asian Americans living with chronic hepatitis B do not know their HBV status. This can endanger not only their own personal health but also that of their partners and families.

Danny Chu, MD Clinical Instructor, Albert Einstein School of Medicine Attending Physician, Beth Israel Medical Center


Low levels of HBV screening in the Asian-American community suggest that an alarming number of infected individuals are going undiagnosed and untreated. — Danny Chu, MD

Updated CDC Recommendations To better diagnose people with chronic hepatitis B, the CDC issued guidelines in September 2008 (Table). It recommends that all foreignborn Asian Americans be tested for HBV and referred to medical care as needed. Clinicians should also be aware that there is no simple cure for HBV, but it can be treated effectively when it’s diagnosed early. Seven FDA-approved medicines are available for chronic HBV, including oncedaily oral antiviral therapies that suppress viral replication. Especially for the Asian-American population, it’s critical that physicians implement the CDC guidelines on routine HBV screening. Stepping up HBV detection and treatment for those at greatest risk may greatly reduce the morbidity and mortality associated with this disease.

Summarizing CDC Screening Recommendations

Table

Routine testing for chronic HBV is recommended for: • People born in geographic regions with HBsAg prevalence of >2%, which includes all Asian countries. • Anyone with HBsAg prevalence of >2%. • Pregnant women. • Infants born to HBsAg-positive mothers. • Household contacts and sex partners of HBV-infected persons. • HIV-infected people. • Men who have sex with men. • Injection-drug users. • People who may have been exposed to HBV who could benefit from post-exposure prophylaxis (eg, needlestick injury to a healthcare worker or sexual assault). Abbreviations: HBV, hepatitis B virus; HBsAg, hepatitis B surface antigen. Source: Adapted from: Weinbaum CM, et al. MMWR Recomm Rep. 2008;57(RR-8):1-20.

Danny Chu, MD, has indicated to Physician’s Weekly that he has worked as a consultant and paid speaker for Gilead, Bristol-Myers Squibb, and Novartis.

References Office of Minority Health. Chronic Hepatitis B in Asian Americans, Native Hawaiians and Other Pacific Islanders: Background. 2008. Available at: http://www.omhrc.gov/templates Nguyen TT, Taylor V, Chen MS Jr, Bastani R, Maxwell AE, McPhee SJ. Hepatitis awareness, knowledge, and screening among Asian Americans. J Cancer Educ. 2007;22:267-272. Chu, ASF Lok, TT Tran, et al. Hepatitis B virus screening practices of Asian-American primary care physicians who treat Asian adults living in the United States. Presented at the International Symposium on Viral Hepatitis and Liver Disease. March 20–24, 2009. Washington, DC. Weinbaum CM, Williams I, Mast EE, et al. Centers for Disease Control and Prevention. Recommendations for identification and public health management of persons with chronic hepatitis B virus infection. MMWR Recomm Rep. 2008;57(RR-8):1-20. Available at: http://www.cdc.gov/mmwr/preview Hepatitis B Foundation. Approved hepatitis B drugs in the United States. 2009. Available at: http://www.hepb.org/patients/hepatitis_b_treatment.htm

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March 1, 2010 • Issue No. 9 Click here to view this article online.

Extending Survival for

HIV-Infected Patients Elena Losina, PhD Director of Methodology Program in HIV Epidemiology/Outcomes Research Division of General Medicine Massachusetts General Hospital Associate Professor of Orthopedic Surgery Brigham and Women’s Hospital Harvard Medical School

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ver the past few decades, advances in antiretro­ viral therapy (ART) have enabled many HIVinfected patients to live longer lives. Despite these successes, substantial avoidable losses in life expectancy of HIV-infected persons persist in the United States. The factors that exert a significant impact on survival include: • Late diagnosis. • Late initiation of care. • Premature discontinuation of therapy.

Background behavioral risk factors include alcohol, substance abuse, and smoking, which are prevalent in individuals with HIV.

Assessing Survival Losses In the November 15, 2009 issue of Clinical Infectious Diseases, my colleagues and I published a study in which we estimated survival losses related to HIV disease in the United States. This included 1) behavioral risk factors in the absence of HIV, 2) HIV disease per se, and 3) late initiation and/or early discontinuation of life saving ART. For individuals who were not infected with HIV and had risk profiles similar to those who were infected, we found that the projected life expectancy, starting at age 33, was 34.6 years, compared with 42.9 years for the general U.S. population. These findings suggested that about 8 fewer years, or a 19% reduction, in life expec­ tancy are due to substance abuse and other high-risk behaviors even in the absence of HIV. These losses underscore the critical importance of interventions that focus on reducing substance abuse and other high-risk behaviors. Patients infected with HIV lost an additional 11.9 years of life if they received HIV care that was concordant with guidelines (representing an addi­tional 28% reduction). The estimated life expectancy for HIV-infected patients who initiated ART very late—when CD4 cell counts reached less

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The high-risk profile of people infected with HIV, the infection itself, and late initiation and early discontinuation of care all appear to lead to substantial decreases in life expectancy. —Elena Losina,PhD than 50 cells/mL—was 8.83 years lower than it was for patients who initiated ART according to current guidelines. Overall, late ART initiation combined with early discontinuation led to additional 3.3 years survival loss (representing an 8% loss of life). These results further emphasize the gap between guidelineconcordant and actual care. Years of life lost from late initiation and early discontinuation were greatest for Hispanic HIV-infected individuals, accounting for 3.90 years. Losses in life expectancy from high-risk behaviors were greater for women than men across all races and ethnicities.

Getting Proactive Our study demonstrated that the high-risk profile of people infected with HIV, the infection itself, and

late initiation and early discontinuation of care all appear to lead to substantial decreases in life expectancy. Considering these findings, clinicians must strive to use interventions that address risky behaviors. Earlier linkage to care and better retention in care are also important, especially among racial/ethnic minorities. The U.S. Department of Health and Human Services has implemented several HIV prevention programs that target racial and ethnic minorities, but greater efforts are required at all levels of healthcare. Recent efforts to expand routine HIV testing throughout the U.S. may further address the problem of earlier diagnosis. Improving access to medical and social services could address additional risk factors for early mortality. The hope is that these efforts may ultimately lead to improved survival for HIVinfected individuals.

Elena Losina, PhD, has indicated to Physician’s Weekly that she has worked as a consultant for and has received grants/research aid from the NIH.

References Losina E, Schackman BR, Sadownik SN, et al. Racial and sex disparities in life expectancy losses among HIV-infected persons in the United States: impact of risk behavior, late initiation, and early discontinuation of antiretroviral therapy. Clin Infect Dis. 2009;49:1570-1578. Available at: www.journals.uchicago.edu/doi/pdf/10.1086/644772 Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the use of antiretroviral agents in HIV-1-infected adults and adolescents. Department of Health and Human Services. December 1, 2009;1-161. Available at www.aidsinfo.nih.gov/ContentFiles/AdultandAdolescentGL.pdf Wood E, Hogg RS, Lima V, et al. Highly active antiretroviral therapy and survival in HIV-infected injection drug users. JAMA. 2008;300:550-554. Nijhawan A, Kim S, Rich J. Management of HIV infection in patients with substance use problems. Curr Infect Dis Rep. 2008;10:432-438. Freedberg KA, Losina E, Weinstein MC, et al. The cost effectiveness of combination antiretroviral therapy for HIV disease. N Engl J Med. 2001;344:824-831. Anastos K, Schneider MF, Gange SJ, et al. The association of race, sociodemographic, and behavioral characteristics with response to highly active antiretroviral therapy in women. J Acquir Immune Defic Syndr. 2005;39:537-544.

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Infectious Disease Update  

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