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We evaluated the association of bone fracture with mortality among persons with HIV, controlling for sociodemographic, behavioral, and clinical factors. Incident fracture was associated with 48% greater risk of all-cause mortality, underscoring the need for bone mineral density screening and fracture prevention. Low bone mineral density (BMD) and fracture are more common among persons with HIV (PWH) than those without HIV infection. We evaluated the association of bone fracture with mortality among PWH, controlling for sociodemographic, behavioral, and clinical factors. We analyzed data from HIV Outpatient Study (HOPS) participants seen at nine US HIV clinics during January 1, 2000, through September 30, 2017. Incident fracture rates and post-fracture mortality were compared across four calendar periods. Cox proportional hazards analyses determined factors associated with all-cause mortality among all participants and those with incident fracture. Among 6763 HOPS participants, 504 (7.5%) had incident fracture (median age = 47 years) and 719 (10.6%) died. Of fractures, 135 (26.8%) were major osteoporotic (hip/pelvis, wrist, spine, arm/shoulder). During observation, 27 participants with major osteoporotic fractures died (crude mortality 2.97/100 person-years [PY]), and 48 with other site fractures died (crude mortality 2.51/100 PY). Post-fracture, age- and sex-adjusted all-cause mortality rates per 100 PY decreased from 8.5 during 2000–2004 to 1.9 during 2013–2017 (P

Background Although chlamydia (CT) and gonorrhea (GC) infections are increasing in the United States, there are limited data on their incidence, testing rates, and associated risk factors among persons living with HIV (PLWH), including by anatomic site among men who have sex with men (MSM). Methods We analyzed 2007–2017 medical records data from Human Immunodeficiency Virus (HIV) Outpatient Study (HOPS) participants in care at 9 HIV clinics. We calculated CT (and GC) incidence and testing rates and assessed associations with sociodemographic and clinical factors using log-linear regression. Results Among 4727 PLWH, 397 had 881 CT infections and 331 had 861 GC infections, with an incidence of 2.95 and 2.88 per 100 person-years, respectively. From 2007 to 2017, incidence and testing rates increased by approximately 3.0- and 1.9-fold for CT and GC, respectively. Multivariable factors associated with incident CT (GC) included younger age, MSM, and prior diagnoses of sexually transmitted diseases (STDs). Among 1159 MSM, 583 (50.3%) had 844 CT and 843 GC tests during 2016–2017, and 26.6% of tests were 3-site (urethra, rectum, and pharynx), yielding the highest rates of CT (GC) detection. Multivariable factors associated with CT (GC) testing included younger age, non-Hispanic/Latino black race, and having prior STDs. Conclusions Recent CT and GC incidence and testing increased among PLWH; however, only half of MSM were tested for CT or GC during 2016–2017 and less than a third of tests were 3-site. To promote sexual health and STD prevention among PLWH who are MSM, research regarding the added value of CT and GC testing across 3 anatomic sites is needed.

To determine if aztreonam as initial empiric treatment of adult septic shock is associated with increased mortality compared to the use of anti-pseudomonal beta-lactam agents.This was a multicenter, retrospective cohort study of 582 adult emergency department patients admitted to 12 acute care facilities within a single health system from January 2014 to December 2017 with septic shock receiving either aztreonam or an anti-pseudomonal beta-lactam for empiric treatment and discharged with an infection-related ICD-9 or ICD-10 code. The primary endpoint was in-hospital mortality.Initial exposure to aztreonam was associated with increased hospital mortality compared to treatment with an anti-pseudomonal beta-lactam agent (22.7% vs. 12.9%, OR = 1.98, 95% CI: 1.27-3.11). When adjusted for APACHE II score, the treatment group effect on mortality remained statistically significant (OR = 1.74, 95% CI: 1.08-2.80). Aztreonam use was also associated with increased utilization of aminoglycosides (28.9% vs. 12.4%, p0.0001) and fluoroquinolones (50.5% vs. 25.8%, p0.01). There was no difference in hospital or intensive care unit length of stay in surviving patients between the two groups.Compared to anti-pseudomonal beta-lactams, empiric treatment with aztreonam is associated with increased mortality and greater antibiotic exposure among patients with acute septic shock. These findings suggest that treatment with anti-pseudomonal beta-lactams should be prioritized over allergy avoidance whenever feasible.

We evaluated the association of bone fracture with mortality among persons with HIV, controlling for sociodemographic, behavioral, and clinical factors. Incident fracture was associated with 48% greater risk of all-cause mortality, underscoring the need for bone mineral density screening and fracture prevention.Low bone mineral density (BMD) and fracture are more common among persons with HIV (PWH) than those without HIV infection. We evaluated the association of bone fracture with mortality among PWH, controlling for sociodemographic, behavioral, and clinical factors.We analyzed data from HIV Outpatient Study (HOPS) participants seen at nine US HIV clinics during January 1, 2000, through September 30, 2017. Incident fracture rates and post-fracture mortality were compared across four calendar periods. Cox proportional hazards analyses determined factors associated with all-cause mortality among all participants and those with incident fracture.Among 6763 HOPS participants, 504 (7.5%) had incident fracture (median age = 47 years) and 719 (10.6%) died. Of fractures, 135 (26.8%) were major osteoporotic (hip/pelvis, wrist, spine, arm/shoulder). During observation, 27 participants with major osteoporotic fractures died (crude mortality 2.97/100 person-years [PY]), and 48 with other site fractures died (crude mortality 2.51/100 PY). Post-fracture, age- and sex-adjusted all-cause mortality rates per 100 PY decreased from 8.5 during 2000-2004 to 1.9 during 2013-2017 (P0.001 for trend). In multivariable analysis, incident fracture was significantly associated with all-cause mortality (Hazard Ratio 1.48, 95% confidence interval 1.15-1.91). Among 504 participants followed post-fracture, pulmonary, kidney, and cardiovascular disease, hepatitis C virus co-infection, and non-AIDS cancer, remained independently associated with all-cause mortality.Incident fracture was associated with 48% greater risk of all-cause mortality among US PWH in care, underscoring the need for BMD screening and fracture prevention. Although fracture rates among PWH increased during follow-up, post-fracture death rates decreased, likely reflecting advances in HIV care.

OBJECTIVES Adiponectin levels are inversely related to cardiovascular risk and are low in diabetics and obese persons. We examined the association between adiponectin concentration and HIV-associated lipodystrophy, which remains unclear. METHODS The Study to Understand the Natural History of HIV/AIDS in the Era of Effective Therapy (SUN) was a prospective cohort study of HIV-infected adults conducted in four US cities. Lean body and fat masses were assessed using dual-energy X-ray absorptiometry scans. Using baseline data from 2004 to 2006, we defined lipodystrophy using a sex-specific fat mass ratio and performed cross-sectional analyses of associated risks using multivariable logistic regression. RESULTS Among 440 male participants (median age 42 years; 68% non-Hispanic white; 88% prescribed combination antiretroviral therapy; median CD4 lymphocyte count 468 cells/μL; 76% with viral load 500 cells/μL (PR 2.59; 95% CI 1.46-4.61), viral load

Background Aztreonam is often given to patients with a documented β-lactam allergy in lieu of a first-line anti-pseudomonal β-lactam (APBL). However, aztreonam offers no gram positive coverage and data suggest that gram negative organisms have lower susceptibility rates to this antibiotic than to APBLs. Septic patients are especially vulnerable to poor outcomes since inappropriate initial antimicrobial therapy has been shown to be an independent predictor of increased mortality. The purpose of this study was to determine whether septic patients treated with aztreonam experience inferior outcomes compared to those treated with an APBL. Methods This was a retrospective, multicenter, cohort study of all adult patients in metro Charlotte Atrium Health facilities treated for sepsis or septic shock from January 2014 to October 2017. Patients receiving either aztreonam or an APBL were identified using the system-wide sepsis database and enrolled in a 1:2 ratio. Patients were excluded if there was no infection-related discharge ICD-9 or ICD-10 code, if they received both aztreonam and an APBL in the first 8 hours, or if they received fewer than 2 doses of the study antibiotic. The primary endpoint was in-hospital mortality. Results A total of 194 patients received aztreonam and 388 patients received an APBL. β-lactam allergies were more common in patients who received aztreonam compared to APBL (97% vs. 14.2%, p < 0.01). In-hospital mortality rates were greater in the patients who received aztreonam vs. APBL (22.7% vs. 12.9%, p = 0.0025). After adjusting for APACHE II score, initial aztreonam exposure remained independently associated with hospital mortality (OR = 1.74, 95% CI: 1.0 – 2.8, p = 0.02). Additionally, we identified an increase in combination therapy with the use of aminoglycosides (28.9% vs. 12.4%, p < 0.0001) and fluoroquinolones (50.5% vs. 25.8%, p < 0.0001) in patients receiving aztreonam. No difference was found in overall length of stay or ICU length of stay. Conclusion In septic patients, the use of aztreonam as the backbone of antimicrobial therapy may result in increased mortality. This highlights the importance of stewardship interventions that obtain an accurate allergy history and encourage the use of APBL antibiotics whenever feasible. Disclosures Kelly E. Pillinger, PharmD, BCIDP, Pharmacy Times (Other Financial or Material Support, Speaker)

HIV-infected persons are living longer on combination antiretroviral therapy (cART) but experiencing more comorbidities including low bone mineral density (BMD). Using data from the Study to Understand the Natural History of HIV and AIDS in the Era of Effective Therapy (SUN Study), we determined the prevalence of low BMD (T-score below one standard deviation of the reference mean) and compared it with matched controls from the National Health and Nutrition Examination Survey (NHANES). We also assessed 4-year longitudinal BMD changes among participants virologically suppressed on cART. Of 653 participants included in this analysis (77% male, 29% black, median age 41 years, median CD4(+) cell count 464 cells/mm(3), 89% with HIV RNA

Objective: To critically evaluate the published literature assessing the safety and efficacy of thrombolytic therapy for massive and submassive pulmonary embolism (PE). Methods: A search of human trials in the English-language (September 2017) was conducted through the MEDLINE database using the following terms: PE, tissue plasminogen activator, tenecteplase, and alteplase. 67 unique articles were identified, of which 24 clinical trials discussing clinical outcomes related to administration of either intravenous tenecteplase or alteplase were included. Results: Thrombolytic therapy with anticoagulation significantly reduced mortality compared to anticoagulation alone in massive PE. In submassive PE, thrombolytics reduced the rate of right ventricular dysfunction and hemodynamic collapse; however, there is an increased risk of major and minor bleeding with no benefit on long-term functional outcomes. Conclusions: Patients with massive PE should receive thrombolytics when no major contraindications to therapy exist. Patients with submassive PE at highest risk for progression to hemodynamic instability should receive anticoagulation and be monitored for clinical deterioration. If an imminent risk of hemodynamic instability or cardiac arrest occurs, thrombolytics should be administered if no contraindications exist. Net mortality benefit and risk of bleeding must be considered when deciding to administer thrombolytic therapy in massive or submassive PE.

Background Colorado hospitals participated in a statewide collaborative to improve the management of inpatient urinary tract infections (UTIs) and skin and soft tissue infections (SSTIs). We evaluated the effects of the intervention on diagnostic accuracy and antibiotic use. Methods The main collaborative outcomes were proportion of UTI diagnoses that met criteria for symptomatic UTI; exposure to fluoroquinolones (UTI only); duration of therapy (UTIs and SSTIs); and exposure to antibiotics with broad gram-negative activity (SSTIs only). Outcomes were compared between pre-intervention and intervention periods overall and by hospital. Secondary analyses were changes in outcome trends by time series analysis. Results Twenty-six hospitals, including 9 critical access hospitals, participated in the collaborative. Data were reported for 4060 UTIs and 1759 SSTIs. Between the pre-intervention and intervention periods, the proportion of diagnosed UTIs that met criteria for symptomatic UTI was similar (51% vs 54%, respectively; P = .10), exposure to fluoroquinolones declined (49% vs 41%; P < .001), and the median duration of therapy was unchanged (7 vs 7 days; P = .99). Among SSTIs, exposure to antibiotics with broad gram-negative activity declined (61% vs 53%; P = .001) and the median duration of therapy declined (11 vs 10 days; P = .03). There was substantial variation in performance among hospitals. By time series analysis, only the declining trend of fluoroquinolone use was significant (P = .03). Conclusions The collaborative model is a feasible approach to engage hospitals in a common antibiotic stewardship intervention. Performance improvement was observed for several outcomes but varied substantially by hospital.

The ASDEX Upgrade (AUG) programme, jointly run with the EUROfusion MST1 task force, continues to significantly enhance the physics base of ITER and DEMO. Here, the full tungsten wall is a key asset for extrapolating to future devices. The high overall heating power, flexible heating mix and comprehensive diagnostic set allows studies ranging from mimicking the scrape-off-layer and divertor conditions of ITER and DEMO at high density to fully non-inductive operation (q95 = 5.5, ) at low density. Higher installed electron cyclotron resonance heating power 6 MW, new diagnostics and improved analysis techniques have further enhanced the capabilities of AUG. Stable high-density H-modes with MW m−1 with fully detached strike-points have been demonstrated. The ballooning instability close to the separatrix has been identified as a potential cause leading to the H-mode density limit and is also found to play an important role for the access to small edge-localized modes (ELMs). Density limit disruptions have been successfully avoided using a path-oriented approach to disruption handling and progress has been made in understanding the dissipation and avoidance of runaway electron beams. ELM suppression with resonant magnetic perturbations is now routinely achieved reaching transiently . This gives new insight into the field penetration physics, in particular with respect to plasma flows. Modelling agrees well with plasma response measurements and a helically localised ballooning structure observed prior to the ELM is evidence for the changed edge stability due to the magnetic perturbations. The impact of 3D perturbations on heat load patterns and fast-ion losses have been further elaborated. Progress has also been made in understanding the ELM cycle itself. Here, new fast measurements of and Er allow for inter ELM transport analysis confirming that Er is dominated by the diamagnetic term even for fast timescales. New analysis techniques allow detailed comparison of the ELM crash and are in good agreement with nonlinear MHD modelling. The observation of accelerated ions during the ELM crash can be seen as evidence for the reconnection during the ELM. As type-I ELMs (even mitigated) are likely not a viable operational regime in DEMO studies of 'natural' no ELM regimes have been extended. Stable I-modes up to have been characterised using -feedback. Core physics has been advanced by more detailed characterisation of the turbulence with new measurements such as the eddy tilt angle—measured for the first time—or the cross-phase angle of and fluctuations. These new data put strong constraints on gyro-kinetic turbulence modelling. In addition, carefully executed studies in different main species (H, D and He) and with different heating mixes highlight the importance of the collisional energy exchange for interpreting energy confinement. A new regime with a hollow profile now gives access to regimes mimicking aspects of burning plasma conditions and lead to nonlinear interactions of energetic particle modes despite the sub-Alfvénic beam energy. This will help to validate the fast-ion codes for predicting ITER and DEMO. This work has been carried out within the framework of the EUROfusion Consortium and has received funding from the Euratom research and training programme 2014–2018 and 2019–2020 under grant agreement No. 633053. The views and opinions expressed herein do not necessarily reflect those of the European Commission. "Article signat per més de 100 autors/es: H. Meyer, for the AUG Team: D. Aguiam, C. Angioni, C.G. Albert, N. Arden, R. Arredondo Parra, O. Asunta, M. de Baar, M. Balden, V. Bandaru, K. Behler, A. Bergmann, J. Bernardo, M. Bernert, A. Biancalani, R. Bilato, G. Birkenmeier, T.C. Blanken, V. Bobkov, A. Bock, T. Bolzonella, A. Bortolon, B. Böswirth, C. Bottereau, A. Bottino, H. van den Brand, S. Brezinsek, D. Brida, F. Brochard, C. Bruhn, J. Buchanan, A. Buhler, A. Burckhart, Y. Camenen, D. Carlton, M. Carr, D. Carralero, C. Castaldo, M. Cavedon, C. Cazzaniga, S. Ceccuzzi, C. Challis, A. Chankin, S. Chapman, C. Cianfarani, F. Clairet, S. Coda, R. Coelho, J.W. Coenen, L. Colas, G.D. Conway, S. Costea, D.P. Coster, T.B. Cote, A. Creely, G. Croci, G. Cseh, A. Czarnecka, I. Cziegler, O. D'Arcangelo, P. David, C. Day, R. Delogu, P. de Marné, S.S. Denk, P. Denner, M. Dibon, A. Di Siena, D. Douai, A. Drenik, R. Drube, M. Dunne, B.P. Duval, R. Dux, T. Eich, S. Elgeti, K. Engelhardt, B. Erdös, I. Erofeev, B. Esposito, E. Fable, M. Faitsch, U. Fantz, H. Faugel, I. Faust, F. Felici, J. Ferreira, S. Fietz, A. Figuereido, R. Fischer, O. Ford, L. Frassinetti, S. Freethy, M. Fröschle, G. Fuchert, J.C. Fuchs, H. Fünfgelder, K. Galazka, J. Galdon-Quiroga, A. Gallo, Y. Gao, S. Garavaglia, A. Garcia-Carrasco, M. Garcia-Muñoz, B. Geiger, L. Giannone, L. Gil, E. Giovannozzi, C. Gleason-González, S. Glöggler, M. Gobbin, T. Görler, I. Gomez Ortiz, J. Gonzalez Martin, T. Goodman, G. Gorini, D. Gradic, A. Gräter, G. Granucci, H. Greuner, M. Griener, M. Groth, A. Gude, S. Günter, L. Guimarais, G. Haas, A.H. Hakola, C. Ham, T. Happel, N. den Harder, G.F. Harrer, J. Harrison, V. Hauer, T. Hayward-Schneider, C.C. Hegna, B. Heinemann, S. Heinzel, T. Hellsten, S. Henderson, P. Hennequin, A. Herrmann, M.F. Heyn, E. Heyn, F. Hitzler, J. Hobirk, K. Höfler, M. Hölzl, T. Höschen, J.H. Holm, C. Hopf, W.A. Hornsby, L. Horvath, A. Houben, A. Huber, V. Igochine, T. Ilkei, I. Ivanova-Stanik, W. Jacob, A.S. Jacobsen, F. Janky, A. Jansen van Vuuren, A. Jardin, F. Jaulmes, F. Jenko, T. Jensen, E. Joffrin, C.-P. Käsemann, A. Kallenbach, S. Kálvin, M. Kantor, A. Kappatou, O. Kardaun, J. Karhunen, S. Kasilov,, Y. Kazakov, W. Kernbichler, A. Kirk, S. Kjer Hansen, V. Klevarova, G. Kocsis, A. Köhn, M. Koubiti, K. Krieger, A. Krivska, A. Krämer-Flecken, O. Kudlacek, T. Kurki-Suonio, B. Kurzan, B. Labit, K. Lackner, F. Laggner, P.T. Lang, P. Lauber, A. Lebschy, N. Leuthold, M. Li, O. Linder, B. Lipschultz, F. Liu, Y. Liu, A. Lohs, Z. Lu, T. Luda di Cortemiglia, N.C. Luhmann, R. Lunsford, T. Lunt, A. Lyssoivan, T. Maceina, J. Madsen, R. Maggiora, H. Maier, O. Maj, J. Mailloux, R. Maingi, E. Maljaars, P. Manas, A. Mancini, A. Manhard, M.-E. Manso, P. Mantica, M. Mantsinen, P. Manz, M. Maraschek, C. Martens, P. Martin, L. Marrelli, A. Martitsch, M. Mayer, D. Mazon, P.J. McCarthy, R. McDermott, H. Meister, A. Medvedeva, R. Merkel, A. Merle, V. Mertens, D. Meshcheriakov, O. Meyer, J. Miettunen, D. Milanesio, F. Mink, A. Mlynek, F. Monaco, C. Moon, F. Nabais, A. Nemes-Czopf, G. Neu, R. Neu, A.H. Nielsen, S.K. Nielsen, V. Nikolaeva, M. Nocente, J.-M. Noterdaeme, I. Novikau, S. Nowak, M. Oberkofler, M. Oberparleiter, R. Ochoukov, T. Odstrcil, J. Olsen, F. Orain, F. Palermo, O. Pan, G. Papp, I. Paradela Perez, A. Pau, G. Pautasso, F. Penzel, P. Petersson, J. Pinzón Acosta, P. Piovesan, C. Piron, R. Pitts, U. Plank, B. Plaum, B. Ploeckl, V. Plyusnin, G. Pokol, E. Poli, L. Porte, S. Potzel, D. Prisiazhniuk, T. Pütterich, M. Ramisch, J. Rasmussen, G.A. Rattá, S. Ratynskaia, G. Raupp, G.L. Ravera, D. Réfy, M. Reich, F. Reimold, D. Reiser, T. Ribeiro, J. Riesch, R. Riedl, D. Rittich, J.F. Rivero-Rodriguez, G. Rocchi, M. Rodriguez-Ramos, V. Rohde, A. Ross1, M. Rott, M. Rubel, D. Ryan, F. Ryter, S. Saarelma, M. Salewski, A. Salmi, L. Sanchis-Sanchez, J. Santos, O. Sauter, A. Scarabosio, G. Schall, K. Schmid, O. Schmitz, P.A. Schneider, R. Schrittwieser, M. Schubert, T. Schwarz-Selinger, J. Schweinzer, B. Scott, T. Semer, E. Seliunin, M. Sertoli, A. Shabbir, A. Shalpegin, L. Shao, S. Sharapov, G. Sias, M. Siccinio, B. Sieglin, A. Sigalov, A. Silva, C. Silva, D. Silvagni, P. Simon, J. Simpson, E. Smigelskis, A. Snicker, C. Sommariva, C. Sozzi, M. Spolaore, A. Stegmeir, M. Stejner, J. Stober, U. Stroth, E. Strumberger, G. Suarez, H.-J. Sun, W. Suttrop, E. Sytova, T. Szepesi, B. Tál, T. Tala, G. Tardini, M. Tardocchi, M. Teschke, D. Terranova, W. Tierens, E. Thorén, D. Told, P. Tolias, O. Tudisco, W. Treutterer, E. Trier, M. Tripský, M. Valisa, M. Valovic, B. Vanovac, D. van Vugt, S. Varoutis, G. Verdoolaege, N. Vianello, J. Vicente, T. Vierle, E. Viezzer, U. von Toussaint, D. Wagner, N. Wang, X. Wang, M. Weiland, A.E. White, S. Wiesen, M. Willensdorfer, B. Wiringer, M. Wischmeier, R. Wolf, E. Wolfrum, L. Xiang, Q. Yang, Z. Yang, Q. Yu, R. Zagórski, I. Zammuto, W. Zhang, M. van Zeeland, T. Zehetbauer, M. Zilker, S. Zoletnik, H. Zohm and the EUROfusion MST1 Team55

Author(s): Conley, Lois J; Bush, Timothy J; Darragh, Teresa M; Palefsky, Joel M; Unger, Elizabeth R; Patel, Pragna; Steinau, Martin; Kojic, E Milu; Martin, Harold; Overton, E Turner; Cu-Uvin, Susan; Hammer, John; Henry, Keith; Wood, Kathleen; Brooks, John T; SUN Study Group | Abstract: BackgroundAnal cancer rates are higher for human immunodeficiency virus (HIV)-infected adults than for uninfected adults. Limited published data exist characterizing the incidence of precursor lesions detected by anal cytology.MethodsThe Study to Understand the Natural History of HIV/AIDS in the Era of Effective Therapy was a prospective cohort of 700 HIV-infected participants in 4 US cities. At baseline and annually thereafter, each participant completed a behavioral questionnaire, and healthcare professionals collected anorectal swabs for cytologic examination and human papillomavirus (HPV) detection and genotyping.ResultsAmong 243 participants with negative baseline results of anal cytology, 37% developed abnormal cytology findings (incidence rate, 13.9 cases/100 person-years of follow-up; 95% confidence interval [CI], 11.3-16.9) over a median follow-up duration of 2.1 years. Rates among men having sex with men, among women, and among men having sex with women were 17.9 cases/person-years of follow-up (95% CI, 13.9-22.7), 9.4 cases/person-years of follow-up (95% CI, 5.6-14.9), and 8.9 cases/person-years of follow-up (95% CI, 4.8-15.6), respectively. In multivariable analysis, the number of persistent high-risk HPV types (adjusted hazard ratio [aHR], 1.17; 95% CI, 1.01-1.36), persistent high-risk HPV types except 16 or 18 (aHR, 2.46; 95% CI, 1.31-4.60), and persistent types 16 or 18 (aHR, 3.90; 95% CI, 1.78-8.54) remained associated with incident abnormalities.ConclusionsThe incidence of abnormal anal cytology findings was high and more likely to develop among persons with persistent high-risk HPV.

BackgroundMonitoring antiretroviral drug resistance can inform treatment recommendations; however, there are few such data from US patients before they initiate ART.MethodsWe analysed data from HIV Outpatient Study (HOPS) participants from nine US HIV clinics who were diagnosed with HIV infection during 1999–2011. Using the IAS-USA December 2010 guidelines, we assessed the frequency of major drug resistance mutations (mDRMs) related to antiretroviral agents in viral isolates from patients who underwent commercial genotypic testing (GT) for resistance before initiating ART. We employed general linear regression models to assess factors associated with having undergone GT, and then factors associated with having mDRM.ResultsAmong 1531 eligible patients, 758 (49.5%) underwent GT before first ART, increasing from 15.5% in 1999–2002 to 75.9% in 2009–11 (P 5.0 log10 copies/mL and those with a first HOPS visit in 2006 or later were significantly (P ConclusionsDuring 1999–2011, GT use among antiretroviral-naive patients became more common, but a quarter of patients in recent years remained untested. The frequency of mDRMs remained stable over time at about 15%.

Author(s): Kojic, Erna Milunka; Conley, Lois; Bush, Tim; Cu-Uvin, Susan; Unger, Elizabeth R; Henry, Keith; Hammer, John; Escota, Gerome; Darragh, Teresa M; Palefsky, Joel M; Brooks, John T; Patel, Pragna | Abstract: Background:Nonavalent (9v) human papilloma virus vaccine targets high-risk human papillomavirus (HR-HPV) types 16, 18, 31, 33, 45, 52, 58, and low-risk 6, 11. We examined prevalence, incidence, and clearance of anal and cervical HR-HPV in HIV-infected women. Methods:The SUN Study enrolled 167 US women in 2004-2006. Anal and cervical specimens were collected annually for cytology and identification of 37 HPV types: 14 HR included: 9v 16, 18, 31, 33, 45, 52, 58; non-9v 35, 39, 51, 56, 59, 66, 68. Results:Baseline characteristics of 126 women included: median age 38 years; 57% non-Hispanic black; 67% HIV RNA l 400 copies/mL; 90% CD4 counts ≥200 cells/mm3. HPV prevalence at anus and cervix was 90% and 83%; for 9v HR-HPV types, 67% and 51%; non-9v HR-HPV, 54% and 29%, respectively. The 9v and non-9v HR-HPV incidence rates/100 person-years were similar (10.4 vs 9.5; 8.5 vs 8.3, respectively); 9v clearance rates were 42% and 61%; non-9v 46% and 59%, in anus and cervix, respectively. Conclusions:Anal HR-HPV prevalence was higher than cervical, with lower clearance; incidence was similar. Although prevalence of non-9v HR-HPV was substantial, 9v HR-HPV types were generally more prevalent. These findings support use of nonavalent vaccine in HIV-infected women.

In a cohort of patients receiving care for HIV, we examined longitudinally the impact of past 30-day frequency of heavy drinking (consuming 5+ drinks on one occasion) on HIV-related (detectable viral load and CD4+ T cell count) and non-HIV-related (hemoglobin and biomarkers of kidney function and liver fibrosis) clinical outcomes and the extent to which these effects were due to reduced antiretroviral therapy (ART) adherence. Data came from the Study to Understand the Natural History of HIV/AIDS in the Era of Effective Therapy. Between March 2004 and June 2006, 533 individuals receiving ART were recruited and followed every 6 months for six years. Using longitudinal mediation analysis, we estimated natural direct effects (NDE) of heavy drinking frequency (never, 1-3 times, or 4+ times in the past 30 days) on clinical outcomes and natural indirect effects (NIE) mediated via ART adherence. A one-level increase in heavy drinking frequency had a significant negative NDE on CD4+ T-cell counts (-10.61 cells/mm3; 95 % CI [-17.10, -4.12]) and a significant NIE through reduced ART adherence of -0.72 cells/mm3 (95 % CI [-1.28, -0.15]), as well as a significant NIE on risk of detectable viral load (risk ratio = 1.03; 95 % CI [1.00, 1.05]). Heavy drinking had a significant detrimental NIE on a combined index of 5-year mortality risk and detrimental NDE and total effect on a biomarker of liver fibrosis. Heavy drinking has deleterious effects on multiple clinical outcomes in people living with HIV, some of which are mediated through reduced ART adherence.

We used a standardized screening tool to examine frequency of depression and its relation to antiretroviral medication adherence among HIV-infected persons on highly active antiretroviral therapy (HAART) in the Study to Understand the Natural History of HIV/AIDS in the Era of Effective Therapy (SUN Study). This is a prospective observational cohort of 700 HIV-infected patients enrolled between March 2004 and June 2006 in four U.S. cities, who completed a confidential audio computer-assisted self-interview [ACASI] with behavioral risk and health-related questions at baseline and 6-month follow-up visits, including the nine-question PRIME-MD depression screener and a validated 3-day antiretroviral adherence question. Among 539 eligible participants receiving HAART, 14% had depression at baseline (22% women, 12% men). In multivariable analysis using generalized estimating equations (GEE) to account for repeated measurements through 24 months of follow-up, persons who reported depression on a given ACASI were twice as likely to report nonadherence to antiretrovirals on the same ACASI (Odds ratio [OR] 2.02, 95% CI: 1.15, 3.57] for mild/moderate depression versus none); such persons were also less likely to have HIV viral load400 copies/mL. Self-administered computerized standardized screening tools can identify at-risk individuals with depression who may benefit from interventions to improve antiretroviral adherence.

Objectives: To determine the prevalence of pre-frailty among HIV-infected persons and associationswith pre-frailty and frailty in this population. Design, Setting and Participants:From a contemporary,prospective observational cohort of HIV-infected persons (SUN Study), we determined, using a cross-sectionalanalytic study design, the proportions of non-frail, pre-frail, and frail persons by the respective presence of 0, 1-2, and ≥ 3 of 5 established frailty criteria: unintentional weight loss, exhaustion, physical-inactivity, weak-gripand slow-walk. We evaluated associations with pre-frailty/frailty using multivariate analysis. Results:Of 322participants assessed (79% men, 58% white non-Hispanic, median age 47 years, 95% on combinationantiretroviral therapy [cART], median CD4 + cell count 641 cells/mm3 and 93% HIV RNA < 400 copies/mL),57% were non-frail, 38% pre-frail, and 5% frail. Age increased from non-frailty through frailty. Notably,however, half of pre-frail and frail participants were < 50 years, and of those, 42% and 100%, respectively, werelong-term unemployed (versus 16% of non-frail counterparts). In multivariate analysis, pre-frail/frailparticipants were more likely to have Hepatitis C seropositivity (adjusted odds ratio [aOR] 3.24, 95% CI: 1.35-7.78), a history of AIDS-defining-illness (aOR 3.51, 95% CI: 1.82-6.76), greater depressive symptoms (aOR1.16, 95% CI:1.09-1.23), higher D-dimer levels (aOR 2.94, 95% CI:1.10-7.87), and were less likely to be whitenon-Hispanic (aOR 0.35, 95% CI: 0.20-0.61). Conclusions:Pre-frailty and frailty are prevalent in the cART eraand are associated with unemployment even among persons < 50 years. Pre-frailty appears to be an intermediatestate in the spectrum from non-frailty through frailty and our characterization of pre-frailty/frailty suggestscomplex multifactorial associations.

BACKGROUND We compared the herpes simplex virus type 2 (HSV-2) seroprevalence in a contemporary HIV cohort with the general US population and determined risk factors for HSV-2 infection among HIV-infected persons. METHODS The Study to Understand the Natural History of HIV and AIDS in the Era of Effective Therapy (SUN) Study is a prospective observational cohort of 700 HIV-infected adults enrolled in 4 U.S. cities between 2004 and 2006. At baseline, participants completed a behavioral risk questionnaire and provided specimens for HSV-2 serology. We calculated HSV-2 seroprevalence, standardized by age, gender, and race among HIV-infected persons compared with the general US adult population, using data from the National Health and Nutrition Examination Survey from 2003 to 2006. We examined risk factors associated with HSV-2 infection among HIV-infected persons using multivariate logistic regression. RESULTS Among 660 (94%) SUN participants with adequate specimens for HSV-2 serologic testing, 548 (83%) were 20 to 49 years old (median age, 39 years; 77% male; 59% non-Hispanic white; median CD4 count, 470 cells/mm; 74% with HIV RNA viral loads

In the combination antiretroviral therapy (cART) era, renal dysfunction remains common. The Study to Understand the Natural History of HIV/AIDS in the Era of Effective Therapy (SUN) (ClinicalTrials.gov number, NCT00146419) is a prospective observational cohort study of HIV-infected adults. At baseline, comprehensive data were collected, including cystatin C and measures of renal function. Univariate and multivariate regression analyses were performed to identify factors associated with baseline renal dysfunction [estimated glomerular filtration rate (eGFR)90 ml/min/1.73 m(2) calculated using the simplified Modification of Diet in Renal Disease equation] and elevated cystatin C (1.0 mg/liter) in a cross-sectional analysis. Among 670 subjects with complete data (mean age 41 years, mean CD4 cell count 530 cells/mm(3), 79% prescribed cART), the mean eGFR was 96.8 ml/min/1.73 m(2). Forty percent of subjects had renal dysfunction; 3.3% had chronic kidney disease (eGFR60 ml/min/1.73 m(2)). Elevated cystatin C was present in 18% of subjects. In multivariate analysis, renal dysfunction was associated with older age, non-Hispanic white race/ethnicity, higher body mass index (BMI), hypertension, higher cystatin C levels, and current prescription of ritonavir. Factors associated with elevated cystatin C included hepatitis C coinfection, hypertension, current smoking, older age, current tenofovir use, detectable plasma HIV RNA, and elevated microalbuminuria. The prevalence of chronic kidney disease (CKD) was low in this contemporary HIV cohort. However, mild to moderate renal dysfunction was common despite the widespread use of cART.

BACKGROUND Persons living with HIV are at increased risk for cardiovascular disease in part because of persistent inflammation and coagulation activation. METHODS We examined whether smoking and heavy episodic alcohol use (defined as 5 or more drinks on one occasion) were associated with greater monocyte activation (soluble CD14) and coagulation (D-dimer) in participants in the Study to Understand the Natural History of HIV and AIDS in the Era of Effective Therapy (the "SUN" Study), a prospective observational cohort. RESULTS Using regression analysis (n = 689), current smoking compared with nonsmoking was associated with significantly elevated soluble CD14 (B = 135.57, 95% confidence interval: 84.95 to 186.19, P < 0.001), whereas heavy alcohol use compared with nonheavy use was associated with significantly lower D-dimer levels (B = -0.059, 95% confidence interval: -0.102 to -0.016, P = 0.007). CONCLUSIONS Smoking cessation should be encouraged by HIV care providers to improve mortality outcomes from all causes of death, particularly cardiovascular disease.

Background. Persons with human immunodeficiency virus (HIV) infection are at risk for premature cardiovascular disease (CVD). Predictors of atherosclerotic disease progression in contemporary patients have not been well described. Methods. Using data from a prospective observational cohort of adults infected with HIV (Study to Understand the Natural History of HIV/AIDS in the Era of Effective Therapy), we assessed common carotid artery intima-media thickness (CIMT) at baseline and year 2 by ultrasound. We examined HIV-associated predictors of CIMT progression after adjusting for age, sex, race/ethnicity, body mass index, smoking, hypertension, diabetes, low-density lipoprotein cholesterol level, and baseline CIMT using linear regression. Results. Among 389 participants (median age at baseline, 42 years; male sex, 77%; median CD4+ cell count at baseline, 485 cells/mm3; 78% receiving antiretroviral therapy), the median 2-year CIMT change was 0.016 mm (interquartile range, −0.003 to 0.033 mm; P < .001). Lesser CIMT progression was associated with a suppressed viral load at baseline (−0.009 mm change; P = .015) and remaining virologically suppressed throughout follow-up (−0.011 mm change; P < .001). After adjusting for additional risk factors and a suppressed viral load during follow-up, nonnucleoside reverse transcriptase inhibitor versus protease inhibitor exposure was associated with lesser CIMT progression (−0.011 mm change; P = .02). Conclusions. Suppressing HIV replication below clinical thresholds was associated with less progression of atherosclerosis. The proatherogenic mechanisms of HIV replication and the net CVD benefit of different antiretroviral drugs should be a focus of future research.

Background Human papillomavirus (HPV) infection of the cervix and related abnormal cervical cytology in HIV-infected women has been well described. Little is known about anal HPV infection in HIV-infected women. Methods The SUN Study is a prospective cohort study of 700 HIV-infected patients including 167 women. At baseline, patients completed a behavioral questionnaire and provided, among other samples, cervical and anal swabs for HPV detection and genotyping and for cytologic examination. Here, we present the available baseline data on the 167 women in the SUN study. Results Baseline results were available for 120 women (median age: 38 years, 57% non-Hispanic black, median CD4 cell count 444.5 cells/mm3), of whom, 77% were taking antiretroviral therapy. The prevalences in the anus and cervix of any HPV were 90% and 83%, respectively (P = 0.039), and of high-risk (HR) types 85% and 70%, respectively, (P = 0.001). There was no significant difference in the prevalences of abnormal cytology between the anus and cervix: 38% and 33%, respectively (P = 0.217). Although the presence of abnormal cervical cytology was associated with the presence of abnormal anal cytology (relative risk: 1.7, P = 0.024), its sensitivity (52.5%) and positive predictive value positive (45.6%) for identifying women with abnormal anal cytology were poor. A history of anal sex was not associated with anal HPV infection or abnormal anal cytology. Conclusions In this cohort of HIV-infected women, anal HPV infection was more prevalent and diverse than cervical HPV infection. Anal cytologic abnormalities were as prevalent as cervical cytologic abnormalities, and although abnormal cervical cytology was predictive of abnormal anal cytology, results were not highly concordant. These data support the need for studies of anal cytologic screening of HIV-infected women.

Background. In the era of highly active antiretroviral therapy (HAART), human immunodeficiency virus (HIV)‐infected persons have higher cardiovascular disease risk. Little is known about asymptomatic abnormalities in cardiac structure and function in this population. Methods. The Study to Understand the Natural History of HIV/AIDS in the Era of Effective Therapy (SUN Study) is a prospective, observational, multi-site cohort of 656 HIV-infected participants who underwent baseline echocardiography during 2004‐2006. We examined prevalence of and factors associated with left ventricular systolic dysfunction (LVSD), diastolic dysfunction (DD), pulmonary hypertension (PHTN), left ventricular hypertrophy (LVH), and left atrial enlargement (LAE). Results. Participant characteristics were as follows: median age, 41 years; 24% women; 29% non-Hispanic black; 73% receiving HAART; and median CD41 cell count, 462 cells/lL. Among evaluable participants, 18% had LVSD, 26% had DD, 57% had PHTN (right ventricular pressure .30 mm Hg), 6.5% had LVH, and 40% had LAE. In multivariate analyses, significant factors (P , .05) associated with LVSD were history of MI, elevated highly sensitive C-reactive protein (hsCRP) level, and current tobacco smoking; for DD, elevated hsCRP level and hypertension; for PHTN, current use of ritonavir; for LVH, hypertension, diabetes, non-white race, female sex with elevated body mass index, calculated as the weight in kilograms divided by the square of height in meters, of >25, elevated hsCRP level, and current use of abacavir; for LAE, hypertension and recent marijuana use. Conclusions. In this large contemporary HIV cohort, the prevalence of subclinical functional and structural cardiac abnormalities was greater than expected for age. Abnormalities were mostly associated with expected and often modifiable risks. Lifestyle modification should become a greater priority in the management of chronic HIV disease.

Treatment of human immunodeficiency virus (HIV) infection with highly active combination antiretroviral therapy has increased survival and shifted the spectrum of HIV-associated morbidity and mortality from opportunistic infections toward a variety of other medical conditions. The prospective cohort Study to Understand the Natural History of HIV and AIDS in the Era of Effective Therapy (SUN Study) monitors the clinical course of HIV-infected individuals treated with combination antiretroviral therapy in 4 US cities. Every 6 months, clinical assessments, medical record abstraction, audio computer-assisted self-interview, and neurocognitive measurements are completed and blood and urine specimens are banked centrally. At enrollment and periodically thereafter, additional techniques such as anal cytology, dual energy x-ray absorptiometry, carotid ultrasonography, echocardiography, and abdominal and cardiac computed tomography are performed. From March 2004 through June 2006, 700 participants were enrolled; median age was 41 years, 76% were men, 58% were non-Hispanic white, 62% were men who have sex with men, 78% were taking combination antiretroviral therapy (of whom 86% had an HIV viral load of

Background Prevalence rates of low bone mineral density (BMD) and bone fractures are higher among HIV-infected adults compared with the general United States (US) population, but the relationship between BMD and incident fractures in HIV-infected persons has not been well described. Methods Dual energy X-ray absorptiometry (DXA) results of the femoral neck of the hip and clinical data were obtained prospectively during 2004-2012 from participants in two HIV cohort studies. Low BMD was defined by a T-score in the interval >-2.5 to Results Among 1,006 participants analysed (median age 43 years [IQR 36–49], 83% male, 67% non-Hispanic white, median CD4+ T-cell count 461 cells/mm3 [IQR 311–658]), 36% ( n=358) had osteopenia and 4% ( n=37) osteoporosis; 67 had a prior fracture documented. During 4,068 person-years of observation after DXA scanning, 85 incident fractures occurred, predominantly rib/sternum ( n=18), hand ( n=14), foot ( n=13) and wrist ( n=11). In multivariable analyses, osteoporosis (adjusted hazard ratio [aHR] 4.02, 95% CI 2.02, 8.01) and current/prior tobacco use (aHR 1.59, 95% CI 1.02, 2.50) were associated with incident fracture. Conclusions In this large sample of HIV-infected adults in the US, low baseline BMD was significantly associated with elevated risk of incident fracture. There is potential value of DXA screening in this population.

Background:: Lack of well-supported evidence clearly defining one agent as superior to the other for use in stress ulcer prophylaxis (SUP) has led to an array of treatment strategies. Studies comparing histamine-2 receptor antagonists (H2RAs) and proton pump inhibitors (PPIs) have shown H2RAs to be non-inferior to PPIs at preventing clinically significant gastric bleeding. This, in addition to the decreased cost associated with H2RAs, has led to the adoption of H2RAs as the preferred agent for SUP at our institution. Objectives:: To evaluate the impact of developing a guideline and removing PPIs from computerized order entry PowerPlans on PPI prescribing for SUP in critically ill patients. Patients and Methods:: Members of the critical care service developed a guideline to direct SUP and removed pantoprazole from two critical care admission PowerPlans. In this interventional study with a historical control, adult patients admitted to the medical or surgical-trauma ICU and prescribed a PPI were evaluated during two time periods before and after the interventions. Patients were excluded if they were receiving a PPI for a reason other than SUP. Patients were assessed daily for an indication for SUP. These included mechanical ventilation, high dose steroids, and coagulopathy. Results:: A total of 92 and 60 patients were included in the pre- and post-intervention groups, respectively. PPI use for SUP was reduced from 38% in the pre-intervention group to 15.6% in the post-intervention group (P < 0.0001). PPI days adjusted for LOS were not different between the pre- and post-intervention groups (84% vs 86%, P = 0.5909). Of the total PPI days, 52.4% (95% CI 48.8 - 56.1) were classified as inappropriate because there was no indication, while the remaining 47.6% (95% CI 43.9 - 51.2) had an indication but should have received a H2RA. The total cost associated with guideline non-adherence was $1802. Conclusions:: Our multifaceted intervention reduced the number of days in which a PPI was prescribed for SUP in the overall ICU population; however, it did not impact the duration of PPI therapy. Patients either had no indication for SUP, or had an indication where less costly H2RAs could have been used. Additional opportunity exists to improve cost-effective prescribing of SUP for critically ill patients.

Antibiotic surgical prophylaxis is often necessary to prevent infection but the benefit of antibiotics must be weighed against the risks which include Clostridium difficile infection (CDI). Previous studies that have evaluated the incidence of CDI in surgical patients have shown that the rates are increasing.1 Infection with CDI has been shown to be an independent predictor of increased length of stay, costs and mortality rates.1

Background Colorado Hospital Association (CHA) led a statewide collaborative to engage hospitals in AMS, focused on interventions for UTI and SSTI. The collaborative goals were to reduce the use of fluoroquinolones (FQs) for UTIs, increase the proportion of diagnosed UTIs meeting objective criteria, reduce exposure to antibiotics with broad Gram-negative activity for SSTI, and shorten treatment durations for UTI and SSTI. We evaluated the effect of the collaborative on these measures. Methods Diagnostic (UTI) and treatment guidance (UTI and SSTI) were developed by a local expert panel. Collaborative methodology was used to engage local hospital AMS teams in guideline implementation. Teams submitted data for 80 cases during the baseline period (2014) and 20 cases per quarter during the intervention period (October 2015–December 2016) for each condition. Primary analyses were changes in trends of the main outcomes by interrupted time series analysis. Secondary analyses were the aggregate changes in the main outcomes between the baseline and intervention periods. Results Twenty-seven acute care hospitals (bed range 15–567) participated in the collaborative. Data were reported for 1,530 UTI and 722 SSTI cases from the baseline period and for 2,514 UTI and 1,030 SSTI cases from the intervention. Interrupted time series analyses of the main outcomes are shown in Figure. The trend in exposure to FQs for UTIs decreased significantly from baseline to the intervention (P = 0.03). Changes in the trends for the other outcomes did not reach statistical significance. In the secondary analyses, exposure to FQs declined from 49% at baseline to 40% during the intervention (UTI), and the proportion of diagnosed UTIs meeting objective criteria increased from 51% to 54% (P = 0.10). Among SSTI cases, exposure to antibiotics with broad Gram-negative activity declined from 61% to 53% (P = 0.001), and the median duration of therapy declined from 13 to 11 days (P Conclusion A statewide collaborative successfully engaged hospitals to participate in AMS. Intended changes in prescribing practices for the collaborative were observed; however, the degree of success varied by outcome. Additional work is needed to explore factors associated with success or lack thereof among the individual hospitals. Disclosures H. Wald, Colorado Hospital Association: Consultant, Consulting fee; T. Hulett, Colorado Hospital Association: Consultant and Employee, Salary; G. Barber, Merck: Speaker’s Bureau, Speaker honorarium

We evaluated whether routine biannual sexually transmitted disease (STD) testing coupled with brief risk-reduction counseling reduces STD incidence and high-risk behaviors.The SUN study is a prospective observational HIV cohort study conducted in 4 US cities. At enrollment and every 6 months thereafter, participants completed a behavioral survey and were screened for STDs, and if diagnosed, were treated. Medical providers conducted brief risk-reduction counseling with all patients. Among men who have sex with men (MSM), we examined trends in STD incidence and rates of self-reported risk behaviors before and after exposure to the risk-reduction intervention. The "preintervention" visit was the study visit that was at least 6 months after enrollment STD screening and treatment and at which the participant was first exposed to the intervention. The "postintervention" visit was 12 months later.Among 216 MSM with complete STD and behavioral data, median age was 44.5 years; 77% were non-Hispanic white; 83% were on highly active antiretroviral treatment; 84% had an HIV RNA level400 copies/mL and the median CD4 (cluster of differentiation 4) count was 511 cells/mm. Twelve months after first exposure to the risk-reduction intervention, STD incidence declined from 8.8% to 4.2% (P = 0.041). Rates of unprotected receptive or insertive anal intercourse with HIV-positive partners increased (19% to 25%, P = 0.024), but did not change with HIV-negative partners or partners of unknown HIV status (24% to 22%, P = 0.590).STD incidence declined significantly among HIV-infected MSM after implementing frequent, routine STD testing coupled with risk-reduction counseling. These findings support adoption of routine STD screening and risk-reduction counseling for HIV-infected MSM.

To better understand the factors associated with HIV- and sexually transmitted disease (STD)-transmitting behavior among HIV-infected persons, we estimated STD prevalence and incidence and associated risk factors among a diverse sample of HIV-infected patients in primary care.We analyzed data from 557 participants in the SUN Study, a prospective observational cohort of HIV-infected adults in primary care in 4 US cities. At enrollment and 6 months thereafter, participants completed an audio computer-assisted self-interview about their sexual behavior, and were screened for genitourinary, rectal, and pharyngeal Neisseria gonorrhoeae and Chlamydia trachomatis infections by nucleic acid amplification testing, and for serologic evidence of syphilis. Women provided cervicovaginal samples and men provided urine to screen for Trichomonas vaginalis by polymerase chain reaction.Thirteen percent of participants had a prevalent STD at enrollment and 7% an incident STD 6 months later. The most commonly diagnosed infections were rectal chlamydia, oropharyngeal gonorrhea, and chlamydial urethritis among the men and trichomoniasis among the women. Other than trichomoniasis, 94% of incident STDs were identified in men who have sex with men. Polysubstance abuse other than marijuana, and having ≥4 sex partners in the 6 months before testing were associated with diagnosis of an incident STD.STDs were commonly diagnosed among contemporary HIV-infected patients receiving routine outpatient care, particularly among sexually active men who have sex with men who used recreational drugs. These findings underscore the need for frequent STD screening, prevention counseling, and substance abuse treatment for HIV-infected persons in care.

Adherence of 95% or greater to highly active combination antiretroviral therapy is generally considered necessary to achieve optimal virologic suppression in HIV-infected patients. Understanding factors associated with poor adherence is essential to improve patient compliance, maximize virologic suppression, and reduce morbidity and mortality.We evaluated baseline data from 528 patients taking antiretrovirals, enrolled from March 2004 to June 2006, in a multicenter, longitudinal, prospective cohort study (the SUN study). Using multiple logistic regression, we examined independent risk factors for non-adherence, defined as reporting having missed one or more antiretroviral doses in the past three days on the baseline questionnaire.Of 528 participants (22% female, 28% black, median age 41 years, and median CD4 cell count 486 cells/mm(3)), 85 (16%) were non-adherent. In the final parsimonious multivariate model, factors independently associated with non-adherence included black race (adjusted odds ratio (aOR): 2.08, 95% confidence interval (CI): 1.20-3.60 vs. white race), being unemployed and looking for work (aOR: 2.03, 95% CI: 1.14-3.61 vs. all other employment categories), having been diagnosed with HIV ≥5 years ago (aOR: 1.95, 95% CI: 1.18-3.24 vs. being HIV-diagnosed5 years ago), drinking three or more drinks per day (aOR: 1.73, 95% CI: 1.02-2.91 vs. drinking3 drinks per day), and having not engaged in any aerobic exercise in the last 30 days (aOR: 2.13, 95% CI: 1.25-3.57).Although the above factors may not be causally related to non-adherence, they might serve as proxies for identifying HIV-infected patients at greatest risk for non-adherence who may benefit from additional adherence support.