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Biomedical subjects

J D Rich

Publications and source records attributed to J D Rich.

At least 19 recordsLinked to original sources
PubMed2001

Blood-borne and sexual transmission of human herpesvirus 8 in women with or at risk for human immunodeficiency virus infection.

BACKGROUND: Human herpesvirus 8 (HHV-8), the causal agent of Kaposi's sarcoma, is transmitted sexually among homosexual men, but little is known of its transmission among women. Although HHV-8 has been detected in blood, there has been no clear evidence of blood-borne transmission. METHODS: We identified risk factors for HHV-8 infection in 1295 women in Baltimore, Detroit, New York, and Providence, Rhode Island, who reported high-risk sexual behavior or drug use. HHV-8 serologic studies were performed with two enzyme-linked immunosorbent assays. RESULTS: In univariate analyses, HHV-8 was associated with black race, Hispanic ethnic background, a lower level of education, and infection with syphilis, the human immunodeficiency virus (HIV), hepatitis B virus (HBV), or hepatitis C virus (HCV). The risk of seropositivity for HHV-8 increased with the frequency of injection-drug use (P<0.001); HHV-8 seroprevalence among the women who used drugs daily was three times that among women who never injected drugs. Among the women with a low risk of sexual transmission, HHV-8 seroprevalence was 0 percent in those who had never injected drugs and 36 percent in those who had injected drugs (P<0.001). However, injection-drug use was linked less strongly to HHV-8 infection than to infection with HBV or HCV. In a multivariate analysis, independent predictors of HHV-8 seropositivity included HIV infection (odds ratio, 1.6; 95 percent confidence interval, 1.1 to 2.2), syphilis infection (odds ratio, 1.8; 95 percent confidence interval, 1.1 to 2.8), and daily injection-drug use (odds ratio, 3.2; 95 percent confidence interval, 1.4 to 7.6). CONCLUSIONS: Both injection-drug use and correlates of sexual activity were risk factors for HHV-8 infection in the women studied. The independent association of HHV-8 infection with injection-drug use suggests that HHV-8 is transmitted through needle sharing, albeit less efficiently than HBV, HCV, or HIV.

Adult↗
PubMed2001

Multicenter evaluation of hepatitis C RNA levels among female injection drug users.

The purpose of this investigation was to identify factors that determine the blood level of hepatitis C virus (HCV) RNA. By use of a quantitative polymerase chain reaction assay, the level of HCV RNA was ascertained in stored serum samples from 676 women enrolled in a multicenter prospective investigation who were seropositive for anti-HCV antibodies. HCV RNA levels ranged from undetectable to 22.4x106 copies/mL in these women. Among the 520 women with detectable HCV RNA, levels were higher among those who were >41 years old and those who had human immunodeficiency virus (HIV) infection. After adjusting for age in a multivariate linear regression model, HCV RNA levels were more strongly associated with HIV RNA levels than with CD4(+) lymphocyte counts. However, <6% of person-to-person variance was explained by the factors evaluated. Additional research is needed to ascertain what determines the level of HCV RNA in blood.

Adolescent↗
PubMed2001

Plasma viral load testing in the management of HIV infection.

The polymerase chain reaction assay, branched DNA assay and nucleic acid sequence-based amplification assay quantitate human immunodeficiency virus (HIV) RNA levels. Plasma viral load (PVL) testing has become a cornerstone of HIV disease management. Initiation of antiretroviral drug therapy is usually recommended when the PVL is 10,000 to 30,000 copies per mL or when CD4+ T-lymphocyte counts are less than 350 to 500 per mm3 (0.35 to 0.50 x 10(9) per L). PVL levels usually show a 1- to 2-log reduction within four to six weeks after therapy is started. The goal is no detectable virus in 16 to 24 weeks. Periodic monitoring of PVL is important to promptly identify treatment failure. When feasible, the same assay should be used for serial PVL testing in the individual patient. At least two PVL measurements usually should be performed before antiretroviral drug therapy is initiated or changed. PVL testing may be helpful in the rare instance of indeterminate HIV antibody testing, especially in a patient with recent infection.

Anti-HIV Agents↗
PubMed2001

Heroin use in adolescents and young adults admitted for drug detoxification.

PURPOSE: To examine heroin use and associated morbidity in young adults undergoing drug detoxification. METHODS: A retrospective chart review of all persons (ages 18-25) admitted to either of the two state-funded detoxification facilities in Rhode Island was conducted between June 1998 and June 1999. Only those reporting heroin as a primary drug were included in this study (N=201). RESULTS: Clients were largely male (64%), and white (79%), with a mean age of 22. Of those that reported heroin as their primary drug, 62% used primarily by injection. Mean age of initiation for heroin use was 18.3 years. Twenty-two percent reported a psychiatric diagnosis, and 80% reported a substance-abusing family member. Injection, previous overdose, and a mother with a history of substance use were associated with early initiation of heroin use. CONCLUSIONS: The majority of young adults with heroin addiction undergoing detoxification began using heroin during late adolescence. Concurrence of psychiatric and medical diagnoses with heroin addiction was common, and may contribute to the severity of drug use. Efforts to identify risk factors for heroin and other injection drug use in adolescents and young adults will be critical for the design of effective interventions to prevent injection drug use and its associated morbidities.

Adolescent↗
PubMed2001

Prescribing syringes to prevent HIV: a survey of infectious disease and addiction medicine physicians in Rhode Island.

This article describes the assessment of physicians' attitudes and practices regarding prescribing syringes to injection drug users (IDUs). A brief, anonymous, self-administered questionnaire was sent to all Infectious Disease and Addiction Medicine specialists in Rhode Island. Of 49 eligible physicians, 39 responded (response rate 80%). Most (95%) indicated that there is a legitimate medical reason for IDUs to obtain sterile syringes. Many (71%) agreed that they would prescribe syringes to prevent disease in IDUs if it were clearly legal to do so. We can conclude that physician syringe prescription to IDUs may be an acceptable supplement to existing HIV prevention strategies.

Adult↗
PubMed2001

Risk factors for syphilis among incarcerated women in Rhode Island.

Syphilis remains a significant problem in the United States. The prison environment is an ideal location to identify and treat syphilis. We undertook this study to describe the correlates and risk factors for syphilis among incarcerated women in Rhode Island. The study design was a review of all cases of syphilis identified through routine screening in the state prison and a case control study. Between 1992 and 1998, among 6,249 incarcerated women, 86 were found to have syphilis; of these, 29 were primary and secondary cases representing 49% of infectious cases of syphilis in women in the state. The prison environment offers a unique opportunity for the diagnosis and treatment of syphilis.

Adult↗
PubMed2001

Successful linkage of medical care and community services for HIV-positive offenders being released from prison.

Human immunodeficiency virus (HIV) infection is more prevalent among the incarcerated than the general population. For many offenders, incarceration is the only time that they may access primary care. Project Bridge is a federally funded demonstration project that provides intensive case management for HIV-positive ex-offenders being released from the Rhode Island state prison to the community. The program is based on collaboration between colocated medical and social work staff. The primary goal of the program is to increase continuity of medical care through social stabilization; it follows a harm reduction philosophy in addressing substance use. Program participants are provided with assistance in accessing a variety of medical and social services. The treatment plan may include the following: mental illness triage and referral, substance abuse assessment and treatment, appointments for HIV and other medical conditions, and referral for assistance to community programs that address basic survival needs. In the first 3 years of this program, 97 offenders were enrolled. Injection drug use was reported by 80% of those enrolled. There were 90% followed for 18 months, 7% moved out of state or died, and 3% were lost to follow-up. Reincarceration happened to 48% at least once. Of those expressing a need, 75% were linked with specialty medical care in the community, and 100% received HIV-related medical services. Of those expressing a need for substance abuse treatment, 67% were successful in keeping appointments for substance abuse treatment within the community. Project Bridge has demonstrated that it is possible to maintain HIV-positive ex-offenders in medical care through the provision of ongoing case management services following prison release. Ex-offenders will access HIV-related health care after release when given adequate support.

Adult↗
PubMed2001

Syringe prescription to prevent HIV infection in Rhode Island: a case study.

Injection drug users (IDUs) are a population at high risk for many diseases, including AIDS, and are clearly in need of medical and substance abuse treatment. Access to sterile syringes is critical for lowering the risk of transmission of HIV and other blood-borne pathogens among IDUs. Previously tried strategies include needle exchange programs and changing laws to allow the legal purchase and possession of syringes. An alternative strategy is to have physicians prescribe syringes to IDUs. To the best of our knowledge, this has previously been tried by only a few physicians in rare situations and never on a programmatic basis. This report describes the genesis of physician's syringe prescription in Rhode Island and some of the lessons learned to date. Because of the illicit nature of drug use, a tremendous amount of mistrust and fear on the part of IDUs often leads to poor interaction with the medical establishment. Prescription of syringes by a physician can serve as a tool for reaching out to a high-risk and often out-of-treatment population of drug users. It is a way for the health care community to tap into drug-using networks and bring those populations into a medical care system.

Adult↗
PubMed2001

Factitious HIV syndrome in young women.

Factitious HIV infection has been observed at our center in women presenting with a false history of HIV/AIDS. In a 2-year period, 4 women presented for HIV-related care, indicating they were HIV-seropositive, while repeated serologic testing revealed no evidence of HIV infection. In all cases, the women were either quite angry or appeared surprised when told that they did not have HIV infection. A common denominator in all 4 women was a history of prolonged sexual, physical, or emotional abuse. Three of the 4 had been to other physicians, changing doctors as soon as the absence of HIV infection was established. Appropriate psychiatric support is an important aspect in care of these women, although it may not be accepted. All presentations of HIV infection should be confirmed either by identifying hard-copy data of HIV test results or by retesting all patients before evaluation and treatment of presumed HIV-related illnesses.

Adaptation, Psychological↗
PubMed2000

Physician prescribing of sterile injection equipment to prevent HIV infection: time for action.

Injection drug users, their sex partners, and their children are at high risk for acquiring HIV infection and other bloodborne diseases. The risk for disease transmission in the United States is partly the result of restricted access to sterile injection equipment. Physicians and pharmacists can play an important role in providing syringe access by prescribing and dispensing syringes to patients who use injection drugs and cannot or will not enter drug treatment Prescribing and dispensing injection equipment are ethical, clinically appropriate, and fully consistent with current public health guidelines on disease prevention. An analysis of the laws of the 50 U.S. states, the District of Columbia, and Puerto Rico finds that physicians in nearly all these jurisdictions may legally prescribe sterile injection equipment to prevent disease transmission among drug-using patients and that pharmacists in most states have a clear or reasonable legal basis for filling the prescriptions. Given these medical and legal findings, physicians may wish to take a larger role in improving access to sterile injection equipment by prescribing this equipment for their patients where this practice is legal, and by joining efforts to change the law where it poses a barrier.

Drug Prescriptions↗
PubMed2000

Laboratory testing for infection with the human immunodeficiency virus: established and novel approaches.

The enzyme-linked immunosorbent assay (ELISA) and the Western blot are the primary tests for the diagnosis and confirmation of human immunodeficiency virus (HIV) infection. The ELISA, an inexpensive screening test for antibodies to HIV-1, is both sensitive and specific. The HIV-1 Western blot is a reliable confirmatory test following a repeatedly reactive ELISA. False-positive HIV-1 results with this sequence of tests are extremely rare but can occur, and test results that are inconsistent with clinical or other laboratory information should be questioned, repeated, or supplemented. The US Food and Drug Administration has also approved rapid and more accessible testing methods. Oral mucosal transudate and urine testing are noninvasive testing methods; rapid and home sample collection kits offer easier access to testing.

Blotting, Western↗
PubMed2000

High street prices of syringes correlate with strict syringe possession laws.

The current epidemic of injection drug use in the United States and abroad has precipitated an increase in transmission of infectious diseases, including human immunodeficiency virus (HIV), hepatitis B, hepatitis C, and human T-lymphotrophic virus II (HTLV-II) in injection drug users (IDUs) who share syringes and other injection equipment. Sharing is often due to a lack of available sterile syringes, which is, in part, a result of laws and regulations controlling the purchase and possession of syringes. These laws, in turn, raise the price of questionably sterile black market syringes, inadvertently encouraging the reuse and sharing of syringes. To date, very little information has been gathered on the street price of syringes in different communities. We surveyed 42 needle exchange programs (NEPs) in the United States in July and August 1998 to determine the street prices of syringes. The relationship among local laws regulating syringe possession, the enforcement of those laws, and street syringe prices was examined. There was a strong correlation between the presence of syringe possession laws and higher street syringe price ($2.87 vs. $1.14, p< .01). In areas with syringe possession laws, cost was significantly higher when laws were perceived to be enforced strictly ($3.66 vs. $2.08, p<.01). Street prices for syringes are an easily quantifiable indirect measure of availability of sterile syringes and may reflect syringe sharing and reuse.

Communicable Disease Control↗
PubMed2000

Adherence to antiretroviral therapy among HIV-infected methadone patients: effect of ongoing illicit drug use.

Methadone maintenance patients infected with human immunodeficiency virus (HIV) currently receiving antiretroviral therapy had HIV RNA testing and were surveyed regarding their adherence to their treatment regimens. Adherence was measured using self-report on four questions relating to medication use in the last day and last month and whether the patient took "drug holidays." Of the patients (N = 42), 52% were receiving two-drug antiretroviral therapy and 48% were receiving triple therapy that included a protease inhibitor. Persons on triple therapy reported higher rates of adherence on all measures and were more likely to have undetectable HIV RNA levels than persons on dual therapy (60% vs. 50%). Ongoing illicit drug injection was the only factor significantly associated (p < .05) with multiple measure nonadherence; however, it was not associated with undetectable HIV RNA level. Levels of nonadherence were comparable to estimates from other chronic diseases, but this finding has important implications for patients receiving highly active antiretroviral therapy.

Antiretroviral Therapy, Highly Active↗
PubMed2000

Central nervous system aspergillosis in patients with human immunodeficiency virus infection. Report of 6 cases and review.

Central nervous system (CNS) aspergillosis is a relatively uncommon complication of human immunodeficiency virus (HIV) infection. We describe 6 patients with the acquired immunodeficiency syndrome (AIDS) who developed CNS aspergillosis, and we review a total of 33 cases of CNS aspergillosis among HIV-infected individuals that were diagnosed by histology and/or culture. All patients were diagnosed with advanced HIV infection. Major risk factors for the disease included neutropenia and corticosteroid use. The most common presenting symptoms were nonspecific neurologic manifestations including headache, cranial or somatic nerve weakness or paresthesia, altered mental status, and seizures. The most common sites of additional Aspergillus involvement were the lungs, sinuses, ears, and orbits, while in one-fourth of the cases CNS was the only site of Aspergillus infection. The final diagnosis of CNS aspergillosis was made on autopsy in more than half the cases, and medical treatment of CNS aspergillosis was unsuccessful in all cases. CNS aspergillosis should be included in the differential diagnosis of HIV-infected patients who present with nonspecific neurologic symptoms and signs. If we take into account the much higher prevalence of invasive aspergillosis of the lungs, the findings in the present report suggest that CNS aspergillosis in HIV-infected individuals occurs more often as a result of direct extension from the sinuses, orbits, and ears than through hematogenous spread from the lungs. Physicians should be aware that the CNS might be the only site of Aspergillus involvement and include CNS aspergillosis in the differential diagnosis of HIV-infected patients presenting with focal neurologic signs and symptoms, especially when the head CT reveals hypodense lesions.

Adult↗
PubMed2000

Strategies to optimize the impact of needle exchange programs.

In the United States today, half of all new HIV infections are injection drug use-associated, many of which are a result of the reuse and sharing of contaminated syringes. Thus, providing access to sterile syringes for injection drug users is an important part of preventing HIV transmission. Needle exchange programs (NEPs) have been established as one successful approach to providing sterile injection equipment. The medical literature shows that these programs are effective in decreasing both syringe sharing and HIV incidence in injection drug users. In addition, many NEPs are also beneficial because they provide other injection drug use-relevant services. There are several strategies that can be adopted in order to optimize the impact of needle exchange programs, at both the community and national levels. These include establishing NEPs in communities that need them, expanding and improving those that already exist, and implementing such programs on a larger national scale with the provision of federal funds.

Acquired Immunodeficiency Syndrome↗