Updates
By Carol A. Kemper, MD, FACP, Section Editor: Updates, Clinical Associate Professor of Medicine, Stanford University, Division of Infectious Diseases; Santa Clara Valley Medical Center, is Associate Editor for Infectious Disease Alert.
High-dose flu vaccine in HIV+
McKittrick N, et al. Improved immunogenicity with high-dose seasonal influenza vaccine in HIV-infected persons. Ann Intern Med 2013;(158):19-26.
Data suggests that persons with HIV infection have lower rates of responsiveness to influenza vaccine compared with the rest of the population. In a preliminary study, protective antibodies were observed in 61% of HIV-infected persons who received H1N1 vaccine. To examine the immunogenicity of higher-dose influenza vaccine in patients with HIV-infection, these authors conducted a randomized double-blinded controlled clinical trial comparing high-dose (60 mcg/strain) vs standard dose (15 mcg/strain) trivalent influenza vaccine. Antibody titers were assessed at baseline and at 3-4 weeks post-vaccination (hemi-agglutination Ab titers ≥ 1:40 were considered sero-protective).
A total of 195 HIV+ persons were enrolled in the study; 190 completed the study; 97 received the higher dose of vaccine and 93 the standard dose. Most of the patients were receiving highly active antiretroviral therapy (88% in the high-dose group and 90% in the standard dose group), and most of them had HIV RNA levels < 400 copies/mL (89% vs 74% respectively). About 10% of participants had CD4 counts < 200 cells/mm3.
The higher dose vaccine did appear to be somewhat more immunogenic in this group of patients. For the H1N1 strain, 96% of the high dose group vs 87% of the standard dose group developed protective antibodies (p <.029); for Influenza H3N2, 96% of the high dose group vs the 92% of the standard dose group developed protective antibodies (p = NS); and for Influenza B, 91% of the high dose group vs 80% of the standard dose group developed protective antibodies (p < .03). The vaccines were similarly well-tolerated. There was a trend towards lower response rates in the few patients with CD4 counts < 200.
A surprising finding from this study was a higher than anticipated baseline rate of seropositivity to influenza, which probably contributed to the higher than anticipated vaccine response. About 50% of the patients in each group demonstrated baseline seroprotective antibody levels to H1N1, H3N2, and Influenza B (ranging from 44% to 52%) — in other words, about half of the patients were receiving a flu booster.
The Good News: HIV care is working (for those with access to care)
Moore RD, et al. Improvement in the health of HIV-infected persons in care: Reducing disparities. Clin Infect Dis 2012;55(9):1242-51.
Advances in HIV care in the United States, especially in disadvantaged people — and the ability to pay for that care, through such critical funding sources such as Ryan White — have made enormous differences in the success of treatment in persons with HIV infection. This article exemplifies the beneficial outcomes of good clinical HIV care and HIV therapeutics in a large urban disadvantaged population in Baltimore.
More than 6,366 patients have been cared for by the Johns Hopkins HIV/AIDS Service from 1995 to 2010, with a cumulative 27,941 person-years of follow-up. Since 1995, the percentage of patients receiving highly active antiretroviral therapy has increased from essentially zero (when such therapy was first introduced) to 87% in 2010. During this period of time, there was no apparent difference in the receipt of HAART based on gender, racial factors or risk group. Over that 15-year period, median CD4 counts have gradually increased and median HIV RNA levels have gradually decreased. By 2010, the median HIV RNA level was < 200 copies/mL — meaning that more than half of the patients were virologically suppressed. And, the median CD4 count had increased to 475 cells/mm3 – which means that half of the patients had essentially a normal number of CD4 cells. A dramatic decline in opportunistic infections was also observed during this period, and by 2010, only 2.4 OIs were documented per 100 patient-years. Mortality also fell to 2.1 per 100 patient-years.
Improvements in outcomes were observed in all patient groups with one exception: average CD4 counts were 76 cells/mm3 lower in patients with IDU compared with MSM; and their HIV RNA levels were on average 0.28 logs greater.
An important factor in the success of this HIV/AIDS program was the ability to retain patients in care — in 2010, 90% of patients remained in care throughout the year. This is despite findings that 73% of persons receiving care at the clinic fell below the federal poverty guideline. Improvements in HIV therapeutics — coupled with the ability to pay for that care — has been critical to the success of large, urban HIV clinics such as this.
The Sad News: Women at Risk for HIV (many without access to care)
Hodder SL, et al. HIV acquisition among women from selected areas of the United States: A cohort study. Ann Intern Med 2013; 158:10-18.
To explore the incidence of HIV infection and behavioral and demographic risk factors for HIV in women at high risk for infection in the United States, these investigators enrolled 2099 high-risk women in a multi-state, longitudinal study for 6 to 12 months (study HPTN 064). They were recruited in 10 different high-risk urban areas throughout the United States. Most of the participants were black (86%) or Hispanic (12%). Criteria for inclusion in the study included 18-44 years of age; at least one episode of unprotected vaginal or anal sex with a man in the previous 6 months; residence in one of the designated high risk areas; and one or more risk factors for HIV (including incarceration, drug use, alcohol dependence, or a male partner with HIV, incarceration, drug use, or alcohol dependence).
A total of 8029 women were screened for the study; 3,233 (40%) were eligible and 2099 returned for enrollment. At entry to study, HIV was detected in 32 women, and 2 other women were found to have acute HIV-infection. Most of the participants (73%) reported both personal and partner risk factors for HIV; 34% reported 3 or more individual risk factors; and 87% reported partner risk factors.
To give an idea of how difficult it is to recruit and retain people into this kind of study, 466 women completed their 6-month visit. Despite the abundance of risk factors, only 4 women became HIV-positive during the study — which sounds like a relatively small number — but calculates out to be a 0.32% annual incidence of HIV infection. This figure is 640% greater than the current 2009 CDC estimate for the annual incidence of HIV infection in black women in the U.S. Remarkably, this study suggests that the risk for HIV-infection in the group of urban, largely black women living in the U.S. is comparable to adults living in sub-Saharan Africa!
Another sad revelation from this study was the high rate of mortality in study participants — 10 women died during the study period (annual mortality rate, 0.61%) — which is also significantly greater than age-adjusted mortality estimates for this age group. Causes of death included diabetic coma, HIV/AIDS, drug overdose, and homicide. The single greatest risk factor for death was drug use (excluding marijuana use). Twenty percent of the women reported they could not obtain health care — most often because they did not know where to find it, how to pay for it, or thought that care was not available.
Sex, Lies, and Technology
Http://www.salon.com/2103/01/15/safe_sex_theres_an_app_for_that/
The internet age has brought all kinds of conveniences and apps for your smart phone, from the popular app “GRINDR” (allowing you a speedy hook-up with the nearest sexually available individual) to the newest MedXSafe, which allows you to literally “bump phones” and share confidential STD and HIV info before you bump into bed. The phone app provides documentation from your doctor of your STD and HIV-disease-free status, just in case your new sexual partner demands certified proof. Apparently you get tested, you then ask your doctor to go to the website, and vouch for your negative lab tests. Of course, a negative test a month ago is no guarantee that an individual might not have since contracted something — or was the “window period” — and be potentially highly contagious.
Aside from the fact that physicians may object to logging on to this site and providing this information — and it’s not clear how the site verifies the credibility of the physician — the website can only provide verification for negative tests — not positive ones, which seems a real limitation. Since the company states the information is secure, wouldn’t it be helpful to provide positive test results as well? Since data suggests that up to 75% of sexually active HIV-seropositive MSM (defined as 2 or more partners in the previous 3 months) find it difficult to disclose their HIV seropositive status, wouldn’t this be a great way to discreetly clue your potential partner into your status, and verify “HIV-compatibility”, without really having to discuss it?
McKittrick N, et al. Improved immunogenicity with high-dose seasonal influenza vaccine in HIV-infected persons. Ann Intern Med 2013;(158):19-26.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content. TESTING
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