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S D Holmberg

Publications and source records attributed to S D Holmberg.

At least 37 records · Page 2Linked to original sources
PubMed1999

Combination antiretroviral therapy and recent declines in AIDS incidence and mortality.

The reasons for recent declines in AIDS incidence and mortality may include advances in treatment, but these may be confounded by earlier declines in the incidence of human immunodeficiency virus (HIV) infection. To determine whether the declines in AIDS and mortality may, in part, stem from wider use of combination antiretroviral therapy, 622 HIV-positive men with well-characterized dates of seroconversion were followed. In this group, combination therapy came into widespread use in only 1996. In a Cox proportional hazards model, the 1996 calendar period was significantly associated with slower progression to AIDS (relative hazard [RH]=0. 19, 95% confidence interval [CI], 0.05-0.69, P=.01) and death (RH=0. 45, 95% CI, 0.21-0.95, P=.04). Declines in incidence of HIV infection, changes in HIV virulence, and end-point underreporting cannot fully explain the decline in AIDS and death in 1996. The introduction of combination antiretroviral therapy as the standard of care may already have had measurable effects.

Acquired Immunodeficiency Syndrome↗
PubMed1999

HIV/AIDS in nonurban Alabama: risk activities and access to services among HIV-infected persons.

BACKGROUND: Because AIDS is increasing in rural areas and small cities of the United States, we sought to further describe the epidemiology of HIV/AIDS in nonurban Alabama. METHODS: Extensive interviews of HIV-infected residents of Alabama living outside of urban Birmingham were conducted at clinics throughout the state. RESULTS: Of the 417 HIV-infected persons interviewed from January 1995 through January 1997, 310 (74%) were male, 229 (55%) were white, and 179 (43%) were black. Over time, increasing proportions of HIV infections have likely been acquired in nonurban areas. Of the 417 subjects, 43 (10%) had visited an STD clinic in the past year, and 31 (7%) had smoked crack-cocaine during the past month. Of the 166 persons who had been sexually active in the past month, 59 (36%) had used alcohol before sex and 56 (34%) used condoms inconsistently. Of the 417 subjects, 161 (39%) currently had no health insurance, and 68 (16%) had lost medical insurance since becoming HIV-infected. CONCLUSION: HIV-infected persons in nonurban Alabama are likely to have practiced high-risk behavior, to have acquired HIV in nonurban settings, and to have inadequate health insurance.

Adolescent↗
PubMed1998

Pneumocystis carinii pneumonia incidence and chemoprophylaxis failure in ambulatory HIV-infected patients. HIV Outpatient Study (HOPS) Investigators.

BACKGROUND: Pneumocystis carinii pneumonia (PCP) remains the most frequently reported serious opportunistic infection in AIDS patients and the second highest cause of mortality among persons with AIDS in the United States, despite the availability of effective chemoprophylaxis. METHODS: To evaluate incidence of PCP and determinants of PCP chemoprophylaxis failure, we analyzed data from 2842 patients visits to infectious diseases physicians at 10 HIV clinics (eight private and two public) in eight U.S. cities from January 1992 through June 1996 as part of the HIV Outpatient Study (HOPS). We performed a time-dependent regression analysis to examine potential determinants of PCP chemoprophylaxis failure. RESULTS: The incidence of chemoprophylaxis failure was 4.6 PCP cases/100 person-years on chemoprophylaxis; these cases represent 67% of all incident episodes of PCP. In a multivariate analysis, the only significant predictors of chemoprophylaxis failure were the use of agents other than trimethoprim-sulfamethoxazole (TMP-SMX), history of prior PCP, and a CD4+ T-lymphocyte cell count of <50 cells/microl. Dosing or frequency of TMP-SMX did not seem to influence risk of chemoprophylaxis failure. DISCUSSION: Chemoprophylaxis failure, especially among those with the most advanced immunosuppression or history of prior PCP, was the most significant source of new PCP cases in the HOPS cohort and thus represents one of the largest contributors to morbidity and mortality in this cohort.

AIDS-Related Opportunistic Infections↗
PubMed1998

Declining morbidity and mortality among patients with advanced human immunodeficiency virus infection. HIV Outpatient Study Investigators.

BACKGROUND AND METHODS: National surveillance data show recent, marked reductions in morbidity and mortality associated with the acquired immunodeficiency syndrome (AIDS). To evaluate these declines, we analyzed data on 1255 patients, each of whom had at least one CD4+ count below 100 cells per cubic millimeter, who were seen at nine clinics specializing in the treatment of human immunodeficiency virus (HIV) infection in eight U.S. cities from January 1994 through June 1997. RESULTS: Mortality among the patients declined from 29.4 per 100 person-years in the first quarter of 1995 to 8.8 per 100 in the second quarter of 1997. There were reductions in mortality regardless of sex, race, age, and risk factors for transmission of HIV. The incidence of any of three major opportunistic infections (Pneumocystis carinii pneumonia, Mycobacterium avium complex disease, and cytomegalovirus retinitis) declined from 21.9 per 100 person-years in 1994 to 3.7 per 100 person-years by mid-1997. In a failure-rate model, increases in the intensity of antiretroviral therapy (classified as none, monotherapy, combination therapy without a protease inhibitor, and combination therapy with a protease inhibitor) were associated with stepwise reductions in morbidity and mortality. Combination antiretroviral therapy was associated with the most benefit; the inclusion of protease inhibitors in such regimens conferred additional benefit. Patients with private insurance were more often prescribed protease inhibitors and had lower mortality rates than those insured by Medicare or Medicaid. CONCLUSIONS: The recent declines in morbidity and mortality due to AIDS are attributable to the use of more intensive antiretroviral therapies.

AIDS-Related Opportunistic Infections↗
PubMed1998

Possible effectiveness of clarithromycin and rifabutin for cryptosporidiosis chemoprophylaxis in HIV disease. HIV Outpatient Study (HOPS) Investigators.

CONTEXT: Cryptosporidium parvum infection, a common cause of diarrhea in persons infected with the human immunodeficiency virus (HIV), is difficult to treat or prevent. OBJECTIVE: To evaluate relative rates of cryptosporidiosis in HIV-infected patients who were either receiving or not receiving chemoprophylaxis or treatment for Mycobacterium avium complex. DESIGN: Analysis of prospectively collected data from HIV-infected patients' visits to their physicians since 1992. SETTING: Ten (8 private, 2 publicly funded) HIV clinics in 9 US cities. PATIENTS: A total of 1019 HIV-infected patients with CD4+ cell counts less than 0.075 x 10(9)/L. MAIN OUTCOME MEASURES: Incidence of clinical cryptosporidiosis during treatment with clarithromycin, rifabutin, and azithromycin. RESULTS: Five of the 312 patients reportedly taking clarithromycin developed cryptosporidiosis vs 30 of the 707 patients not taking clarithromycin (relative hazard [RH], 0.25 [95% confidence interval (CI), 0.10-0.67]; P=.004). Two of the 214 patients taking rifabutin developed cryptosporidiosis vs 33 of the 805 not taking rifabutin (RH, 0.15 [95% CI, 0.04-0.62]; P=.01). Prophylactic efficacy of either drug was 75% or greater. No protective effect was seen in the 54 patients reportedly taking azithromycin (RH, 1.48 [95% CI, 0.44-5.04]; P=.46). CONCLUSIONS: Clarithromycin and rifabutin were highly protective against development of cryptosporidiosis in immune-suppressed HIV-infected persons in this analysis; further study is warranted.

AIDS-Related Opportunistic Infections↗
PubMed1997

Design and baseline participant characteristics of the Human Immunodeficiency Virus Epidemiology Research (HER) Study: a prospective cohort study of human immunodeficiency virus infection in US women.

The prospective, multisite human immunodeficiency (HIV) Epidemiology Research Study was established to define the biologic, psychologic, and social effects of HIV infection on the health of US women. From 1993 to 1995, a total of 871 HIV-infected women and 439 demographically matched, uninfected women aged 16-55 years, half of whom reported injection drug use and half of whom reported only sexual risk behaviors, were recruited in four US cities. Two sites recruited primarily from medical/drug therapy care settings, and two recruited from community sources. Women consented to biannual interviews; physical examination; blood, urine, and cervicovaginal specimen collection and repository; laboratory assays; and abstraction of outpatient and inpatient medical records to document HIV and acquired immunodeficiency syndrome-related diagnoses. Retention was greater than 88% at the third 6-month follow-up. Lower retention was associated with currently injecting drugs, not having dependent children, and not being infected with HIV at enrollment. In addition to the core study, a variety of nested studies are under way, some in collaboration with other HIV cohorts and various Public Health Service agencies. This cohort is distinct from other HIV longitudinal cohorts in the diversity of its participants and the comprehensive range of measures to study prospectively the biomedical, social, and emotional effects of the HIV epidemic on infected women and those whose behavior puts them at high risk of infection.

Adolescent↗
PubMed1996

Crack cocaine smokers who turn to drug injection: characteristics, factors associated with injection, and implications for HIV transmission. The Multicenter Crack Cocaine and HIV Infection Study Team.

A survey of 1220 street-recruited crack cocaine smokers revealed that crack smokers may turn to drug injection to ease crack withdrawal. Crack smokers who later injected tended to smoke crack more heavily and for longer periods than those who did not inject. The initiation of injection was significantly associated with ever snorting heroin (prevalence ratio [PR] = 3.4, 95% confidence interval [CI] = 2.0-5.9) or snorting heroin specifically while smoking crack (PR = 2.3, 95% CI = 1.3-4.0), suggesting that snorted heroin use may mediate the transition to injection among crack smokers. Programs to prevent and treat crack dependence may prevent later injection and injection-related infections including HIV.

Adolescent↗
PubMed1996

Kaposi's sarcoma-associated herpesvirus infection prior to onset of Kaposi's sarcoma.

OBJECTIVES: Kaposi's sarcoma-associated herpesvirus (KSHV), a newly discovered human gammaherpesvirus, is found in the majority of KS lesions from patients with and without AIDS. Peripheral blood mononuclear cells (PBMC) were examined for KSHV DNA to determine whether viral infection precedes onset of this neoplasm. DESIGN: Randomized and blinded case-control study of prospectively collected PBMC samples from ongoing cohort studies. METHODS: Paired PBMC drawn before and after KS onset from 21 AIDS-KS patients were compared to paired PBMC from 23 high-risk HIV-infected homo-/bisexual patients who did not develop KS and to a single PBMC sample from 19 low-risk, HIV-infected hemophiliac patients. Extracted DNA samples were amplified by polymerase chain reaction (PCR) using two non-overlapping nested primer sets to control for potential PCR contamination. RESULTS: In all comparisons, patients who went on to develop KS were significantly more likely to show evidence of KSHV infection prior to onset of KS than either control group. Of PBMC samples from AIDS-KS patients drawn prior to KS, 52% were positive for KSHV DNA whereas both high- and low-risk control groups had lower rates of PBMC infection (9-13%). KSHV infection can precede KS onset by up to 21 months among AIDS-KS patients. CONCLUSIONS: AIDS-KS patients are significantly more likely to show evidence of KSHV infection in PBMC prior to KS onset than control HIV-infected patients. Because identical PBMC samples from cases and controls were examined blindly, these results are not caused by a bias in tissue sampling. Homo-/bisexual and hemophiliac AIDS patients who do not develop KS appear to have a low prevalence of infection. These findings indicate that KSHV infection is specifically associated with the subsequent development of KS in AIDS patients.

AIDS-Related Opportunistic Infections↗
PubMed1996

The acceptability of voluntary HIV antibody testing in the United States: a decade of lessons learned.

OBJECTIVE: As the benefits of early diagnosis of HIV increase, US adults are more likely to be offered HIV counseling and testing in settings where they may not seek testing. Rates and determinants of counseling and testing acceptance in these settings are poorly understood. DESIGN: We reviewed articles and abstracts published from 1985 to 1995 which addressed rates or determinants of counseling and testing acceptance in facilities that provide perinatal, family planning, gynecology, sexually transmitted disease (STD) and drug treatment services, hospitals, and prisons. Data reflected testing experience of more than 240,000 adults. RESULTS: Acceptance rates varied widely (3-100%), even within settings of the same type. Acceptance was generally higher (> 50%) among persons at high risk for acquiring or transmitting the infection (e.g., STD patients, pregnant women at high risk) than among low-risk persons. Factors associated with high acceptance rates included the client's perception of HIV risk, acknowledging risk behaviors; confidentiality protections; presenting counseling and testing as 'routine' rather than optional; and the provider's belief that counseling and testing will benefit the client. Factors associated with low acceptance rates included prior HIV testing, fears about coping with results, and explicit informed consent. CONCLUSIONS: To institute and evaluate counseling and testing programs for persons who do not specifically seek testing, multiple determinants of acceptance must be considered. Practices that protect confidentiality, endorse counseling directed to a client's unique circumstances, and highlight the medical and social benefits of testing are likely to promote acceptance. Acceptance of counseling and testing offered nonroutinely to the numerous Americans who have been previously tested or are at low risk is likely to be low.

Acquired Immunodeficiency Syndrome↗
PubMed1996

The estimated prevalence and incidence of HIV in 96 large US metropolitan areas.

OBJECTIVES: This study sought to estimate the size and direction of the human immunodeficiency virus (HIV) epidemic in US metropolitan statistical areas (MSAs) with populations greater than 500,000. METHODS: A "components model" from review of more than 350 documents, several large datasets, and information from 220 public health personnel was used. Data review focused on injection drug users, men who have sex with men, and high-risk heterosexual men and women. RESULTS: In the 96 MSAs, there are, broadly, an estimated 1.5 million injection drug users, 1.7 million gay and bisexual men, and 2.1 million at-risk heterosexuals, and, among them, an estimated 565,000 prevalent and 38,000 incident HIV infections. This implies about 700,000 prevalent and 41,000 new HIV infections yearly in the United States. Roughly half of all estimated new infections are occurring among injection drug users, most of them in northeastern cities, Miami, and San Juan. Gay and bisexual men still represent most prevalent HIV infections, although incidence--except in young and minority gay men--is much lower now than it was a decade ago. Relatively high prevalences of HIV in at-risk heterosexual persons in several cities indicate the potential for an increase in transmission among them. CONCLUSIONS: This review and synthesis outline the comparative epidemiology of HIV in major US cities and identify populations for interventions.

Female↗
PubMed1996

The association between cigarette smoking and selected HIV-related medical conditions.

OBJECTIVE: To clarify the effect of cigarette smoking on the development of conditions associated with HIV infection. DESIGN: Prospective and retrospective cohort study, with interview and examination twice a year since 1988. METHODS: Data on 516 HIV-infected men from cohorts of homosexual and bisexual men in San Francisco, Denver and Chicago, who were repeatedly interviewed and examined between 1988 and 1992, were analysed. After excluding men who did not have well-defined dates of seroconversion and those who were classified as ex- or intermittent smokers, 232 men remained for analysis: 106 were smokers and 126 were non-smokers. Univariate and Kaplan-Meier survival analyses were performed to assess the relationship between cigarette smoking and loss of CD4+ T-lymphocytes, diagnosis of any AIDS-defining illness, and specific diagnosis of Kaposi's sarcoma, Pneumocystis carinii pneumonia (PCP), oral candidiasis, hairy leukoplakia, and community-acquired pneumonia. RESULTS: By univariate analyses, cigarette smoking was not associated with clinical AIDS, loss of CD4+ cells, Kaposi's sarcoma or PCP, but was significantly associated with oral candidiasis [relative risk (RR), 1.32; 95% confidence interval (CI), 1.02-1.70], hairy leukoplakia (RR, 1.51; 95% CI, 1.15-1.99), and community-acquired pneumonia (RR, 2.62; 95% CI, 1.30-5.27). Dose-response effect was also evident for these three conditions (all P < 0.01). Kaplan-Meier survival analysis indicated no association between cigarette smoking and time of progression to clinical AIDS, Kaposi's sarcoma (KS), or PCP (P = 0.62, 0.54 and 0.11, respectively) but showed that cigarette smokers developed oral candidiasis, hairy leukoplakia, and pneumonia more quickly than non-smokers (P = 0.031, 0.006 and 0.009, respectively). CONCLUSIONS: Cigarette smoking was not associated with an increased likelihood or rate of developing KS, PCP or AIDS, but was associated with developing community-acquired pneumonia, oral candidiasis, and hairy leukoplakia in these HIV-infected men.

AIDS-Related Opportunistic Infections↗
PubMed1995

Recent infection with human immunodeficiency virus and possible rapid loss of CD4 T lymphocytes.

To assess a hypothesized trend that persons recently infected with the human immunodeficiency virus (HIV) may have more rapid declines in absolute CD4 T-lymphocyte (CD4+ cell) counts than those who were HIV-infected in earlier years, sequential CD4+ cell counts in three groups who had definable dates of HIV seroconversion between 1978 and 1992 were reviewed. The CD4+ cell counts examined were from some of the longest extant studies in the United States: 100 homosexual and bisexual men engaged in ongoing observational cohort studies in San Francisco, Denver, and Chicago since 1978 (Group 1); 89 persons in South Carolina infected after 1986 (Group 2); and 155 injecting drug users participating in an observational cohort study in Baltimore since 1988 (Group 3). For all groups, individually and in the aggregate, mean CD4+ cell counts declined rapidly in the first year after HIV infection and then stabilized. However, there was no clear trend for lower (or higher) CD4+ cell counts by fixed time after HIV seroconversion among those seroconverting in recent compared with earlier calendar years. These data do not support a hypothesized trend for more rapid loss of CD4 T lymphocytes--and, by implication, more pathogenic strains of HIV-1--among persons acquiring HIV infection in recent years.

CD4 Lymphocyte Count↗
PubMed1995

The spectrum of medical conditions and symptoms before acquired immunodeficiency syndrome in homosexual and bisexual men infected with the human immunodeficiency virus.

The full range and occurrence of medical conditions in persons infected with human immunodeficiency virus (HIV) before they develop illnesses that define acquired immunodeficiency syndrome (AIDS) have not been systematically or completely described. In a retrospective and prospective cohort study, 1,073 homosexual and bisexual men in three US cities were interviewed and examined twice per year from January 1988 to September 1992. Study participants were from San Francisco, California (273 HIV-seropositive and 432 HIV-seronegative men), Denver, Colorado (107 positive and 129 negative men), and Chicago, Illinois (54 positive and 78 negative men). A total of 305 HIV-positive men had specifiable dates of HIV seroconversion (mean of 15.3 months between the last negative and the first positive HIV antibody test). Besides much increased incidences of thrush (incidence relative risk (IRR) = 23.3) and hairy leukoplakia (IRR = 551), the following conditions also occurred significantly more frequently in HIV-positive men than in HIV-negative men: anal herpes (incidence density (ID) = 10.7/100 person-years; IRR = 7.7); sinusitis requiring antibiotics (ID = 6.2/100 person-years; IRR = 2.1); anal warts (ID = 5.8/100 person-years; IRR = 2.7); seborrhea (ID = 3.8/100 person-years; IRR = 6.6); community-acquired pneumonia (ID = 1.4/100 person-years; IRR = 2.7); skin cancers (ID = 1.0/100 person-years; IRR = 2.2); and seizures, often apparently "breaking through" prior anticonvulsant therapy (ID = 0.8/100 person-years; IRR = 5.6). First episodes of hairy leukoplakia, thrush, and skin cancer occurred at low mean CD4 counts (mean counts were less than 350 cells/microliters) and late in HIV infection (mean times were more than 8 years after HIV seroconversion). Many medical problems, some not widely appreciated, occur in HIV-infected men before they develop AIDS-defining illnesses, signifying considerable morbidity from pre-AIDS HIV infection.

AIDS-Related Opportunistic Infections↗
PubMed1995

Urban rape survivors: characteristics and prevalence of human immunodeficiency virus and other sexually transmitted infections. Multicenter Crack Cocaine and HIV Infection Study Team.

OBJECTIVE: To determine the prevalence of recent rape, the characteristics or recent rape survivors, and the seroprevalence of human immunodeficiency virus (HIV), syphilis, and genital herpes (HSV-2) among recent rape survivors. METHODS: We surveyed women 18-29 years old who were recruited from places unassociated with medical or drug treatment or the criminal justice system in three urban communities where illicit drug use is common. We compared characteristics and HIV, syphilis, and HSV-2 seroprevalence of women who reported recent rape with those of women who denied recent rape. RESULTS: One hundred fifty-one of 1104 (13.7%) women reported having been raped in the year before our interview. Rape survivors were more likely than women who denied recent rape to smoke crack cocaine (86.8 versus 56.7%; odds ratio [OR] 5.0, 95% confidence interval [CI] 3.2-7.8), to be homeless (17.2 versus 6.1%; OR 3.2, CI 2.0-5.2), to report a recent sexually transmitted disease (38.7 versus 18.7%; OR 2.7, CI 1.9-3.9), and to be infected with syphilis (42.4 versus 28.4%; OR 1.9, CI 1.3-2.6) and HSV-2 (71.9 versus 57.5%; OR 1.9, CI 1.3-2.8). Survivors were more likely to acknowledge any HIV risk behavior (including sex work) (85.4 versus 49.5%; OR 5.9, CI 3.9-9.0) and to be HIV-infected (23.3 versus 13.4%; OR 1.9, CI 1.3-2.9). Rape was not independently associated with HIV (OR 0.8, 95% CI 0.4-1.3), syphilis (OR 0.9, 95% CI 0.6-1.3), or HSV-2 (OR 1.3, 95% CI 0.9-2.0) infections after adjustment for confounding factors. CONCLUSION: One in seven women reported being raped recently. Rape was most common among sex workers, crack smokers, and the homeless. Most survivors reported HIV risk behaviors, and many were HIV-infected. Programs to prevent repeated rape, voluntary HIV counseling and testing, and other medical and social services may benefit survivors in these and similar communities.

Adolescent↗
PubMed1995

Treatment options for vulvovaginal candidiasis, 1993.

Vulvovaginal candidiasis (VVC), the second most common form of vaginitis, particularly affects women of childbearing age. Since the 1970s, several new agents have become available for the treatment of VVC. This review focuses on options for the treatment of this condition, critically evaluating the relevant published studies. For the treatment of acute episodes of VVC in nonpregnant women, several topical and oral antifungal agents are clinically and mycologically effective. Topical agents should be considered the first line of therapy; however, oral agents are sometimes associated with better compliance among patients. For acute episodes in pregnant women, a topical agent is the treatment of choice. Until data become available on the treatment of VVC in women infected with human immunodeficiency virus (HIV), the same approach as that used for women without HIV infection should be considered as previously written. For recurrent VVC, the optimal maintenance therapy has not yet been established; however, administration of low-dose oral ketoconazole (100 mg/d) has proven effective. Well-designed studies of the best therapy for VVC in women with HIV infection and for recurrent VVC are urgently needed.

Acute Disease↗
PubMed1994

Intersecting epidemics--crack cocaine use and HIV infection among inner-city young adults. Multicenter Crack Cocaine and HIV Infection Study Team.

BACKGROUND AND METHODS: The smoking of "crack" cocaine is thought to be associated with high-risk sexual practices that accelerate the spread of infection with the human immunodeficiency virus (HIV). We studied 2323 young adults, 18 to 29 years of age, who smoked crack regularly or who had never smoked crack. The study participants, recruited from the streets of inner-city neighborhoods in New York, Miami, and San Francisco, were interviewed and tested for HIV. This report presents the findings for the 1967 participants (85 percent) who had never injected drugs. RESULTS: Of the 1137 crack smokers, 15.7 percent were positive for HIV antibody, as compared with 5.2 percent of the 830 nonsmokers (prevalence ratio adjusted for the city, 2.4; 99 percent confidence interval, 1.7 to 3.6). The prevalence of HIV was highest among the crack-smoking women in New York (29.6 percent) and Miami (23.0 percent). Of the 283 women who had sex in exchange for money or drugs, 30.4 percent were infected with HIV as compared with 9.1 percent of the 286 other women (prevalence ratio, 3.1; 99 percent confidence interval, 1.9 to 5.1); of the 91 men who had anal sex with other men, 42.9 percent were infected with HIV as compared with 9.3 percent of the 582 men who did not have anal sex with other men (prevalence ratio, 4.7; 99 percent confidence interval, 3.0 to 7.4). In multivariable analyses, these high-risk sexual practices accounted for the higher prevalence of HIV infection among the crack smokers, as compared with those who did not smoke crack. Women who had recently had unprotected sex in exchange for money or drugs were as likely to be infected as men who had had sex with men (40.9 percent vs. 42.9 percent). CONCLUSIONS: In poor, inner-city communities young smokers of crack cocaine, particularly women who have sex in exchange for money or drugs, are at high risk for HIV infection. Crack use promotes the heterosexual transmission of HIV.

Adolescent↗