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Biomedical subjects

Timothy P Flanigan

Publications and source records attributed to Timothy P Flanigan.

At least 19 recordsLinked to original sources
PubMed2006

A success story: HIV prevention for injection drug users in Rhode Island.

BACKGROUND: New HIV diagnoses related to injection drug use (IDU) have declined in the United States. Access to clean syringes and decreasing HIV transmission among injection drug users have been HIV prevention priorities of the Rhode Island (RI) HIV community. To examine trends in IDU-related new HIV diagnoses in RI, we performed a retrospective analysis of new HIV diagnoses according to HIV risk factor from 1990-2003. RESULTS: There has been an 80% absolute reduction in IDU-related new HIV diagnoses in RI coincident with IDU-specific prevention efforts. CONCLUSION: There has been a greater decline in IDU-related new HIV diagnoses in Rhode Island compared to national data reported by the Centers for Disease Control and Prevention. We hypothesize that this dramatic decline in Rhode Island is related to extensive HIV prevention efforts targeting IDUs. Further research is needed to examine the impact of specific HIV prevention interventions for injection drug users.

Causality↗
PubMed2006

Bacterial pneumonia, HIV therapy, and disease progression among HIV-infected women in the HIV epidemiologic research (HER) study.

BACKGROUND: To determine the rate and predictors of community-acquired bacterial pneumonia and its effect on human immunodeficiency virus (HIV) disease progression in HIV-infected women, we performed a multiple-site, prospective study of HIV-infected women in 4 cities in the United States. METHODS: During the period of 1993-2000, we observed 885 HIV-infected and 425 HIV-uninfected women with a history of injection drug use or high-risk sexual behavior. Participants underwent semiannual interviews, and CD4+ lymphocyte count and viral load were assessed in HIV-infected subjects. Data regarding episodes of bacterial pneumonia were ascertained from medical record reviews. RESULTS: The rate of bacterial pneumonia among 885 HIV-infected women was 8.5 cases per 100 person-years, compared with 0.7 cases per 100 person-years in 425 HIV-uninfected women (P < .001). In analyses limited to follow-up after 1 January 1996, highly active antiretroviral therapy (HAART) and trimethoprim-sulfamethoxazole (TMP-SMX) use were associated with a decreased risk of bacterial pneumonia. Among women who had used TMP-SMX for 12 months, each month of HAART decreased bacterial pneumonia risk by 8% (adjusted hazard ratio [HR(adj)], 0.92; 95% confidence interval [CI], 0.89-0.95). Increments of 50 CD4+ cells/mm3 decreased the risk (HR(adj), 0.88; 95% CI, 0.84-0.93), and smoking doubled the risk (HR(adj), 2.12; 95% CI, 1.26-3.55). Bacterial pneumonia increased mortality risk (HR(adj), 5.02; 95% CI, 2.12-11.87), with adjustment for CD4+ lymphocyte count and duration of HAART and TMP-SMX use. CONCLUSIONS: High rates of bacterial pneumonia persist among HIV-infected women. Although HAART and TMP-SMX treatment decreased the risk, bacterial pneumonia was associated with an accelerated progression to death. Interventions that improve HAART utilization and promote smoking cessation among HIV-infected women are warranted.

Adolescent↗
PubMed2006

Reasons for modification of generic highly active antiretroviral therapeutic regimens among patients in southern India.

OBJECTIVE: To describe reasons for modification and discontinuation of antiretroviral regimens in association with adverse events (AEs), treatment failure, and cost among patients in southern India. METHODS: Secular trends of patients initiating highly active antiretroviral therapy (HAART) between January 1996 and October 2004 at a tertiary HIV referral center in India were analyzed using a previously validated natural history database. RESULTS: All previously antiretroviral therapy-naive patients who initiated HAART (N = 1443) and had at least 1 follow-up visit were evaluated. The median CD4 count at the time of initiating HAART was 108 cells/microL. The most common first-line regimens were stavudine (d4T) plus lamivudine (3TC) plus nevirapine (NVP) (63%), zidovudine (AZT) plus 3TC plus NVP (19%), d4T plus 3TC plus efavirenz (EFV) (9%), and AZT plus 3TC plus EFV (4%). Twenty percent of patients modified their first-line regimen. The most common reason for modifying therapy was the development of an AE (64%), followed by cost (19%) and treatment failure (14%), with median times to modify therapy being 40, 151, and 406 days, respectively. Common AEs were itching and/or skin rash (66%), hepatotoxicity (27%), and anemia (23%). Nine percent of patients discontinued therapy entirely after a median duration of 124 days, primarily because of cost (64%). CONCLUSION: The most common reason for modifying therapy was the occurrence of AEs, whereas cost was the most common reason for discontinuing therapy. Despite increasing access to lower cost generic HAART in India, even less expensive and more tolerable first-line regimens and cost-effective treatment monitoring tools need to be introduced to achieve better treatment outcomes and access in resource-constrained settings.

Acquired Immunodeficiency Syndrome↗
PubMed2006

Unprotected sex with multiple partners: implications for HIV prevention among young men with a history of incarceration.

OBJECTIVES: The objectives of this study were to describe preincarceration risk behaviors of young men and identify correlates of unprotected sex with multiple partners during the 3 months before incarceration. STUDY: Data on preincarceration risk behaviors were obtained from 550 men, aged 18 to 29 years, in state prisons in California, Mississippi, Rhode Island, and Wisconsin. Correlates of unprotected sex with multiple partners were determined by logistic regression. RESULTS: Of 550 participants, 71% had multiple sex partners, 65.1% had sex with a partner they perceived as risky, and 45.3% engaged in unprotected sex with multiple partners. Men who drank heavily (odds ratio [OR], 1.68; 95% confidence interval [CI], 1.11-2.54) or who had a risky partner (OR, 3.90; 95% CI, 2.60-5.85) were more likely to report unprotected sex with multiple partners. Men who attended religious gatherings (OR, 0.66; 95% CI, 0.46-0.96) or lived in stable housing (OR, 0.69; 95% CI, 0.48-1.00) were less likely to report unprotected sex with multiple partners. CONCLUSIONS: Most participants engaged in behaviors that could result in a sexually transmitted disease, including HIV. Prevention programs should address the relationship between heavy alcohol use and risky sexual behavior. Discharge planning should address housing needs. Faith-based community organizations may play an important role for some young men in their transition to the community.

Adolescent↗
PubMed2005

The changing natural history of HIV disease: before and after the introduction of generic antiretroviral therapy in southern India.

The number of individuals seeking treatment for infection with human immunodeficiency virus increased as the cost of highly active antiretroviral therapy (HAART) decreased 20-fold after the introduction of generic HAART in India in the year 2000. The incidence of tuberculosis and opportunistic infections decreased to <2 cases per 100 person-years. Death rates decreased from 25 to 5 deaths per 100 person-years between 1997 and 2003.

AIDS-Related Opportunistic Infections↗
PubMed2005

The use of community-based modified directly observed therapy for the treatment of HIV-infected persons.

Directly observed therapy, which has been successful in the treatment of tuberculosis, is being adapted for the treatment of HIV to decrease long-term morbidity and mortality. We describe the experiences of 69 HIV-infected individuals who were enrolled in a community-based modified directly observed therapy (MDOT) program. Participants were referred by their primary care physicians based on nonadherence to antiretroviral therapy, and/or active substance use. A near-peer outreach worker initially delivered medications to participants 5 to 7 days per week, with visits subsequently tapered to 1 to 3 days per week after 3 or more months. Questionnaires were completed and laboratory values were obtained at baseline, 1 month, and every 3 months after enrollment. At enrollment, 96% of participants had a history of substance use, 71% had a history of incarceration, and 93% were experienced with highly active antiretroviral therapy (HAART). At the time of their 6-month assessment visit, 31 of 69 participants were receiving observed therapy visits. The median baseline plasma viral load (PVL) was 4.8 log, and the median individual change in PVL from baseline to 6 months among participants receiving MDOT was a decrease of 2.7 log. Reasons why participants were not receiving visits included medication holidays, hospitalization or assisted living, incarceration, discontinuation of program involvement, and death. These results support that MDOT should be included in the spectrum of options available to enhance adherence to HAART among patients who are unsuccessful with self-administration of their medications.

Adult↗
PubMed2005

Lessons learned from use of highly active antiretroviral therapy in Africa.

BACKGROUND: Because antiretrovirals are becoming increasingly available in developing countries, we reviewed the findings of studies that have documented highly active antiretroviral therapy (HAART) use in Africa to identify lessons learned. With the World Health Organization (WHO) guidelines used as a frame of reference, we assessed the feasibility of implementing such programs in Africa. Moreover, clinical and laboratory outcomes were compiled to determine the effectiveness of HAART programs. METHODS: We searched academic databases and recent conference abstracts for studies, and we included all studies that documented patients receiving HAART in Africa. In particular, we examined studies for such program features as type of regimen and frequency of monitoring, in addition to evaluations of patient outcomes. RESULTS: Twenty-eight articles and abstracts involving studies from 14 African countries were reviewed. Overall, 6052 patients (96.4%) were receiving HAART, mainly consisting of 2 nucleoside reverse-transcriptase inhibitors (NRTIs) and 1 nonnucleoside reverse-transcriptase inhibitor. All studies reported an increase in mean and median CD4 cell counts, and a median of 73% of patients achieved undetectable viral loads by the end of the study period. Monitoring of CD4 cell count and viral load at 6-month intervals was completed by all studies. The median weight gained was 5.0 kg, and the median mortality rate was 7.4% (range, 0%-27%). Six studies reported that 68%-99% of patients took >95% of medications. Five studies measured drug resistance; most cases of resistance involved NRTIs. CONCLUSIONS: Many studies reported positive health outcomes, including high levels of treatment adherence that were comparable to those of industrialized countries. Regimens and monitoring means based on WHO guidelines were implemented--and at times, exceeded--in all studies reviewed. We found compelling evidence that HAART can be feasibly administered in resource-limited settings.

Africa↗
PubMed2005

Use of community-based, directly observed therapy for HIV infection: lessons learned for treatment of hepatitis C virus infection.

Directly observed therapy (DOT) is an effective approach for the treatment of tuberculosis among substance users. We have adapted this model to treat human immunodeficiency virus infection. Our experience suggests that community-based, modified DOT should be explored further as a means to treat infectious diseases and chronic medical illnesses for persons with drug dependence; it may be especially pertinent for the treatment of hepatitis C virus infection. DOT can both optimize adherence and provide a way to offer psychosocial support and linkages to social, addiction, psychiatric, and other services, to help address many of the challenges faced by persons with substance abuse disorders.

Adult↗
PubMed2005

Rapid viral load suppression following generic highly active antiretroviral therapy in Southern Indian HIV-infected patients.

We prospectively studied the initial results of 6 months of generic efavirenz-based therapy on the plasma viral load in 40 patients at YRG Centre for AIDS Research and Education, a tertiary HIV referral centre in southern India. The median baseline plasma viral load was 259,000 copies/ml and at 6 months 95% of patients had plasma viral loads less than 400 copies/ml. The data support the use of generic non-nucleoside reverse transcriptase inhibitor-based regimens in resource-limited settings.

Adult↗
PubMed2005

It is time to implement routine, not risk-based, HIV testing.

Approximately one-quarter of a million persons in the United States who are infected with human immunodeficiency virus (HIV) do not know it. To decrease the number of such persons, primary care providers should make HIV testing a routine component of health care. HIV testing should also be offered routinely in other settings, such as emergency departments, jails, and substance abuse treatment centers. Currently, the Centers for Disease Control and Prevention and the Infectious Diseases Society of America recommend routine HIV testing only in settings where the prevalence of HIV infection is > or =1%; in settings where the prevalence of HIV infection is <1%, testing should be based on risk assessment. Because of the impracticality of strategies for testing that are based on estimates of prevalence, and because of the inaccuracy of risk assessment, we propose that HIV testing be routinely offered to any person who is sexually active. As an adjunct to the implementation of routine testing programs, counseling practices need to be streamlined, and rapid HIV testing needs to be implemented in the appropriate settings.

Diagnostic Tests, Routine↗
PubMed2005

Apathy correlates with cognitive function but not CD4 status in patients with human immunodeficiency virus.

Apathy is a prominent neuropsychiatric symptom associated with human immunodeficiency virus (HIV). The increased frequency of apathy in this population may reflect the direct involvement of the virus on the central nervous system (CNS), but the severity of apathy has not been shown to consistently relate to markers of disease activity or other neuropsychiatric complications of the virus. We examined the relationship between ratings of apathy and performance on measures of cognitive function and immune system status in a sample of HIV-infected patients. Apathy was significantly elevated among HIV-infected individuals compared to healthy comparison subjects. Apathy was significantly related to performance on measures of learning efficiency and a measure of cognitive flexibility. Ratings of apathy did not relate to CD4 cell count, but they were associated with disease duration. In addition, ratings of depression were independent of ratings of apathy. These findings suggest that apathy does not co-vary with a proxy measure of active disease status, but apathy does relate to several measures of cognitive dysfunction in patients with HIV. As such, the increased prevalence of apathy among HIV-infected adults may reflect HIV-associated neurologic dysfunction.

Adult↗
PubMed2005

Apathy is associated with volume of the nucleus accumbens in patients infected with HIV.

Apathy refers to a reduction in self-initiated behavior, and it is commonly reported by patients infected with human immunodeficiency virus (HIV). It remains unclear whether apathy among HIV patients reflects a direct effect of the virus on subcortical brain circuits or a secondary neuropsychiatric symptom. In the present study we examined the relationship between ratings of apathy and quantitative analysis of the nucleus accumbens (NA), a subcortical brain structure that regulates initiation of behavioral activation. Twelve HIV-positive individuals without dementia were administered the Marin Apathy Scale and underwent neuroimaging. Voxel-based quantification of the nucleus accumbens was completed using a segmentation protocol. Results of our study revealed that increased ratings of apathy were significantly correlated with lower volume of the nucleus accumbens. By contrast, ratings of depression were unrelated to either apathy or nucleus accumbens volume. These findings provide preliminary evidence that apathy reflects direct involvement of the central nervous system in patients with HIV.

Adult↗
PubMed2005

A diagnostic dilemma in a patient receiving antiretroviral and antituberculosis therapy.

A southern Indian HIV-infected man with tuberculosis (TB) presented with worsening pulmonary infiltrates and increased mediastinal lymphadenopathy because of immune reconstitution 10 days after initiation of HAART. This case highlights the importance of developing guidelines for management of concurrent HIV infection and TB in the developing world.

AIDS-Related Opportunistic Infections↗