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Biomedical subjects

W el-Sadr

Publications and source records attributed to W el-Sadr.

At least 19 recordsLinked to original sources
PubMed1999

Safer sex strategies for women: the hierarchical model in methadone treatment clinics.

Women clients of a methadone maintenance treatment clinic were targeted for an intervention aimed to reduce unsafe sex. The hierarchical model was the basis of the single intervention session, tested among 63 volunteers. This model requires the educator to discuss and demonstrate a full range of barriers that women might use for protection, ranking these in the order of their known efficacy. The model stresses that no one should go without protection. Two objections, both untested, have been voiced against the model. One is that, because of its complexity, women will have difficulty comprehending the message. The second is that, by demonstrating alternative strategies to the male condom, the educator is offering women a way out from persisting with the male condom, so that instead they will use an easier, but less effective, method of protection. The present research aimed at testing both objections in a high-risk and disadvantaged group of women. By comparing before and after performance on a knowledge test, it was established that, at least among these women, the complex message was well understood. By comparing baseline and follow-up reports of barriers used by sexually active women before and after intervention, a reduction in reports of unsafe sexual encounters was demonstrated. The reduction could be attributed directly to adoption of the female condom. Although some women who had used male condoms previously adopted the female condom, most of those who did so had not used the male condom previously. Since neither theoretical objection to the hierarchical model is sustained in this population, fresh weight is given to emphasizing choice of barriers, especially to women who are at high risk and relatively disempowered. As experience with the female condom grows and its unfamiliarity decreases, it would seem appropriate to encourage women who do not succeed with the male condom to try to use the female condom, over which they have more control.

Acquired Immunodeficiency Syndrome↗
PubMed1997

Weekly fluconazole for the prevention of mucosal candidiasis in women with HIV infection. A randomized, double-blind, placebo-controlled trial. Terry Beirn Community Programs for Clinical Research on AIDS.

BACKGROUND: Candidiasis is a frequent complication of infection with the human immunodeficiency virus (HIV); however, few data exist about the natural history, prevention, and treatment of mucosal candidiasis in women. OBJECTIVE: To evaluate the safety and effectiveness of weekly fluconazole prophylaxis for mucosal candidiasis in women infected with HIV. DESIGN: Randomized, double-blind, placebo-controlled trial. SETTING: 14 sites participating in the Community Programs for Clinical Research on AIDS (CPCRA). PATIENTS: 323 women with HIV infection and CD4+ cell counts of 300 cells/mm3 or less. INTERVENTION: 200 mg of fluconazole per week or placebo. Open-label fluconazole for candidiasis prophylaxis was permitted after two oropharyngeal or vaginal episodes or one esophageal episode. MEASUREMENTS: Development of mucosal candidiasis, clinical and in vitro resistance of Candida species to fluconazole, survival, and adverse events. RESULTS: After a median follow-up of 29 months, 72 of 162 patients receiving fluconazole and 93 of 161 patients receiving placebo had at least one episode of candidiasis (relative risk [RR], 0.56 [95% Cl, 0.41 to 0.77); P < 0.001). Weekly fluconazole was effective in preventing oropharyngeal candidiasis (RR, 0.50 [Cl, 0.33 to 0.74]; P < 0.001) and vaginal candidiasis (RR, 0.64 [Cl, 0.40 to 1.00]; P = 0.05) but not esophageal candidiasis (RR, 0.91 [Cl, 0.48 to 1.72]; P > 0.2). Relative risks were similar for women who had a history of mucosal candidiasis (RR, 0.5 [Cl, 0.35 to 0.75]) and those who did not (RR, 0.69 [Cl, 0.35 to 1.34]). Absolute risk reduction for patients with a history of infection was 25.6 per 100 person-years, which is more than twice the reduction of 11.2 per 100 person-years seen in patients with no history of infection. This difference reflects the higher risk of patients who previously had an infection. Candida albicans was not usually resistant to fluconazole in vaginal specimens in clinical or in vitro settings; such resistance occurred in less than 5% of patients in each group. CONCLUSIONS: Weekly fluconazole (200 mg) seems to be safe and effective in preventing oropharyngeal and vaginal candidiasis. This regimen has a useful role in the management of HIV-infected women who are at risk for recurrent mucosal candidiasis.

AIDS-Related Opportunistic Infections↗
PubMed1996

The accurate diagnosis of oral lesions in human immunodeficiency virus infection. Impact on medical staging.

OBJECTIVE: To compare identification of oral candidiasis (OC) and oral hairy leukoplakia (OHL) by medical examiners and oral/dental examiners and to assess the impact of these diagnoses on the medical staging of the human immunodeficiency virus (HIV). DESIGN: Retrospective analysis of data collected by medical and oral/dental examiners at the baseline examination of a prospective study. SETTING: Homosexual men and men and women who were parenteral drug users residing in New York City, enrolled in a longitudinal cohort study. SUBJECTS: A total of 245 individuals participated in this study. MAIN OUTCOME MEASURES: The diagnoses of OC and OHL as recorded in the medical and oral/dental charts were analyzed retrospectively for the same medical and oral/dental evaluation visits. The medical staging of HIV infection based on that evaluation was analyzed concomitantly. RESULTS: Among homosexual men, the oral/dental examiners diagnosed OC in 11% of the individuals and the medical examiners in 4%. In the same cohort, OHL was diagnosed by the oral/dental examiners in 14% of the individuals and by the medical examiners in 8%. Among the parenteral drug users the oral/dental examiners diagnosed OC in 29% of the individuals while the medical examiners made this diagnosis in 11%. In the same cohort, OHL was diagnosed by the oral/dental examiners in 9% of the individuals and by the medical examiners in 2%. The OC and OHL diagnoses affected the medical staging of 12% of the HIV-positive homosexual men and of 22% of the HIV-positive parenteral drug users. Forty percent of the HIV-positive homosexual men and 79% of the HIV-positive parenteral drug users with stage-defining oral lesions were not properly identified by the medical examiners. CONCLUSIONS: Specific training and a comprehensive oral examination have a significant impact on the diagnoses of OC and OHL, and on the medical staging of individuals with HIV infection.

Candidiasis, Oral↗
PubMed1996

Directly observed therapy for tuberculosis: the Harlem Hospital experience, 1993.

OBJECTIVES: A directly observed therapy program was established at Harlem Hospital, New York, NY, in 1993 to promote high tuberculosis treatment completion rates. METHODS: The Harlem program used an on-site surrogate family model. Treatment completion rate, visit adherence rate, human immuno-deficiency virus seroprevalence, and time to sputum culture conversion were assessed. RESULTS: Out of 145 enrolled patients with suspected and confirmed tuberculosis, 95 (92 confirmed and 3 suspected) continued treatment. The visit adherence rate was 91.1 +/- 7.9%, with one patient (1%) lost to follow-up. CONCLUSION: High rates of treatment completion and visit adherence were achieved because of unique program characteristics. Thus, directly observed therapy is advocated as a means of ensuring treatment completion.

AIDS-Related Opportunistic Infections↗
PubMed1995

Multidrug-resistant tuberculosis in patients without HIV infection.

BACKGROUND: Investigations of outbreaks of multidrug-resistant tuberculosis have found low rates of treatment response and very high mortality, and they have mainly involved patients with advanced human immunodeficiency virus (HIV) infection. For patients without HIV infection, one study reported an overall rate of response to treatment of 56 percent, and the mortality from tuberculosis was 22 percent. We investigated treatment response and mortality rates in 26 HIV-negative patients in New York with multidrug-resistant tuberculosis. METHODS: We obtained detailed data from seven teaching hospitals in New York City on patients with multidrug-resistant tuberculosis--defined as tuberculosis resistant at least to isoniazid and rifampin--who were HIV-negative on serologic testing. Lengths of times from diagnosis to the initiation of appropriate therapy and from the initiation of appropriate therapy to conversion to negative cultures were assessed. Therapeutic responses were evaluated by both microbiologic and clinical criteria. RESULTS: Between March 1991 and September 1994, 26 HIV-negative patients were identified and treated. Of the 25 patients for whom adequate data were available for analysis, 24 (96 percent) had clinical responses; all 17 patients for whom data on microbiologic response were available had such a response. The median times from diagnosis to the initiation of appropriate therapy and from the initiation of therapy to culture conversion were 44 days (range, 0 to 181) and 69 days (range, 2 to 705), respectively. Side effects requiring the discontinuation of medication occurred in 4 of 23 patients (17 percent) who were treated with second-line antituberculosis medications. The median follow-up for the 23 patients who responded and who received appropriate therapy was 91 weeks (range, 41 to 225). CONCLUSIONS: In this report from New York City, HIV-negative patients with multidrug-resistant tuberculosis, contrary to previous reports, responded well to appropriate chemotherapy, both clinically and microbiologically.

Adult↗
PubMed1995

Difference in clinical implications of CD4 counts among HIV-infected homosexual men and injection drug using men and women.

While the relationship between CD4 counts and clinical symptoms is well established among homosexual men, the same is not true for injection drug using men and women (IDUM and IDUW). In this paper we investigate whether CD4 counts have the same clinical implications for IDUM and IDUW as for homosexual men. We estimated the CD4 counts at which 50 per cent of the HIV-infected but AIDS-free population has AIDS related complex (ARC) based on three biannually measured CD4 counts. The analyses involve interval, right and left censored threshold data. We took the parametric approach, assuming that the threshold values for ARC arise from a family of distributions that includes symmetric, left or right skewed distributions, in which the logistic and extreme value distributions are embedded as special cases. The resulting estimates of median thresholds of CD4 counts for ARC were 249, 424 and 755 for homosexual men, IDUM, and IDUW, respectively. The results were robust with respect to the assumptions on the underlying distribution.

AIDS-Related Complex↗
PubMed1995

Unrecognized human immunodeficiency virus infection in the elderly.

BACKGROUND: Human immunodeficiency virus (HIV) infection among the elderly has not been appreciated in the United States. This is the result of their exclusion from targeted HIV-testing programs and the perception that they were not at significant risk. METHODS: To assess the extent of HIV infection among elderly patients, we retrieved excess serum samples from patients 60 years or older without a history of HIV infection who died during a 1-year period at our institution. Serum samples were tested for the presence of HIV antibodies and the charts of all those found to be infected with HIV were reviewed. RESULTS: Thirteen (5.05%) of 257 serum samples were HIV-antibody positive. Six (6.2%) of 92 men and seven (8.9%) of 78 women between the ages of 60 and 79 years were infected with HIV. In this group there was a trend toward more women having HIV infection. The death of none of the 13 patients with HIV infection was attributable to HIV infection. CONCLUSIONS: Elderly patients from certain high HIV seroprevalence communities may be at significant risk of HIV infection. The impact of this unrecognized infection on their health, their clinical outcome, and their treatment needs further evaluation. The HIV prevention and education programs should include the elderly, and further studies of HIV seroprevalence among this population should be supported.

Aged↗
PubMed1995

The Harlem family model: a unique approach to the treatment of tuberculosis.

With the increased incidence of tuberculosis and especially of resistant cases in the United States, directly observed therapy as a mechanism for ensuring completion of therapy has been advocated. This mechanism has been primarily pioneered and utilized in developing countries. Few models have been tailored to specific patient populations in this country. At Harlem Hospital, in recognition of the special needs and characteristics of our patients with tuberculosis, we have developed a unique program. This program revolves around a family model with all components of the program contributing to the cohesiveness of all the program participants and staff. In the brief period since its inception, the program has been successful in enrolling and retaining a large number of patients with tuberculosis.

Ambulatory Care↗
PubMed1994

Oral manifestations of HIV infection in homosexual men and intravenous drug users. Study design and relationship of epidemiologic, clinical, and immunologic parameters to oral lesions.

This article describes the baseline findings from a study designed to compare the oral manifestations of HIV infection in homosexual men and intravenous drug users. Both seropositive and seronegative persons were studied. A standard examination instrument was developed to record indexes of oral disease as well as to record the presence of oral lesions. The two groups differed in terms of education, race, socioeconomic status, employment status, housing, and smoking experience. The prevalence and type of oral lesions differed in the two seropositive groups. In seropositive homosexual men, white lesions on the tongue (28.4%) predominated; whereas for the seropositive intravenous drug users, oral candidiasis (43.0%) and gingival marginal erythema (33.3%) were most often detected. We also observed that seronegative intravenous drug users displayed a greater number of oral lesions than seronegative homosexual men. For seropositive homosexual men, lesion presence was significantly associated with decreased levels of CD4; positive associations were seen with current smoking, antiviral drug use, and antibiotic use, and a negative association was observed with current employment. In contrast, only exposure to antiviral drugs was significantly correlated with lesion presence for seropositive intravenous drug users. This baseline analysis from our longitudinal study suggests clear differences in oral manifestations of HIV infection between seropositive homosexual men and intravenous drug users and between seronegative homosexual men and intravenous drug users. Among other parameters, it is apparent that lifestyle, access to health care, and the condition of the oral cavity before infection influence the development of oral lesions in persons with HIV infection.

AIDS-Related Opportunistic Infections↗
PubMed1994

Streptococcus bovis bacteremia and meningitis associated with Strongyloides stercoralis colitis in a patient infected with human immunodeficiency virus.

We present a case of human immunodeficiency virus (HIV) infection complicated by Streptococcus bovis meningitis and bacteremia and severe Strongyloides stercoralis colitis. The association between S. bovis infection and strongyloidiasis has not been described previously. This case highlights the importance of searching for larvae of S. stercoralis as part of the evaluation of the gastrointestinal tract of patients with bacteremia or meningitis due to certain enteric organisms. The role of HIV infection in the development of severe S. stercoralis colitis in association with S. bovis bacteremia and meningitis is unclear.

AIDS-Related Opportunistic Infections↗
PubMed1994

HIV-1 seroprevalence in chest clinic and hospital tuberculosis patients in New York City, 1989-1991.

OBJECTIVE: To describe more fully HIV-1 and tuberculosis (TB) coinfection in TB patients attending New York City Department of Health chest clinics (1989-1991) and one inner-city hospital (1990-1991). DESIGN: An unlinked serosurvey using HIV-1-antibody testing of remnant blood specimens collected for routine medical purposes. SUBJECTS: A total of 1414 clinic and 856 hospital patients. OUTCOME MEASURES: HIV seropositivity and TB infection/disease. RESULTS: A total of 327 (23%) of the clinic patients were HIV-1-positive, with a significantly higher seroprevalence in men (29 versus 15%, P < 0.001) and in young and middle-aged adults aged 30-50 years (P < 0.001). HIV-1 prevalence by TB diagnostic class was: class 2 (purified protein derivative-positive and chest radiograph-negative), 11% (64 out of 570); class 3 (active disease), 34% (197 out of 582); class IV (old/inactive disease), 30% (39 out of 130). Of the hospital patients 487 (57%) were HIV-1-positive. HIV-1 seroprevalence was 55% for those who were identified or believed to be HIV-1-negative on admission as indicated on the medical chart. HIV-1 seroprevalence in the clinic population decreased initially, but later increased, although not to study onset levels. CONCLUSIONS: There is considerable overlap between the TB and HIV epidemics in New York City; a part of the increasing TB incidence may be independent of HIV coinfection. The control of TB will necessitate prompt diagnosis of TB and HIV-1, appropriate TB treatment and/or chemoprophylaxis, and a greater commitment to tackle the social conditions associated with the spread of the disease.

Adolescent↗
PubMed1994

Managing early HIV infection. Agency for Health Care Policy and Research.

This Quick Reference Guide for Clinicians contains highlights from the Clinical Practice Guideline on Evaluation and Management of Early HIV Infection, which was developed by a private-sector panel of health care providers and consumers. Selected aspects of evaluating and managing patients, both adults and children, who are in the early stages of human immunodeficiency virus infection are presented. Topics covered include disclosure of HIV status, monitoring of CD4 lymphocyte counts, prevention of Pneumocystis carinii pneumonia and infection with Mycobacterium tuberculosis, initiation of antiretroviral therapy, treatment of syphilis, eye and oral care, performance of Papanicolaou smears, diagnosis of HIV infection in infants and children, preventive therapy for PCP and assessment of neurologic problems in HIV-infected children, pregnancy counseling, and development of a comprehensive case management system. Algorithms are included that show the sequence of events related to evaluating and managing early HIV infection in adults and children, as well as drug dosing tables for antiretroviral, PCP, and M. tuberculosis therapies.

Adolescent↗
PubMed1993

Sexual functioning in HIV+ and HIV- injected drug-using women.

As part of a natural history study of HIV disease in injected drug users, 38 HIV positive (HIV+) asymptomatic or low-symptomatic women and 37 HIV negative (HIV-) women, mostly of minority inner-city background, underwent a comprehensive survey of sexual functioning. At study baseline, the sample as a whole showed a relatively high prevalence of problems in all major phases of the sexual response cycle and in vaginismus and vaginal pain. Statistically significant group differences indicate higher rates of problems in sexual functioning in HIV+ women even at an early stage of disease progression.

Adult↗