Evaluation of Adherence to Guideline-Based Bone Mineral Density Screening in Veterans with HIV.

People with HIV (PWH) have a higher prevalence of bone mineral density (BMD) loss compared to people without HIV. The Infectious Diseases Society of America (IDSA) recommends BMD screening through dual energy X-ray absorptiometry (DXA) in PWH starting at age 50. We aimed to evaluate adherence to this recommendation in a population of Veterans with HIV (VWH). Retrospective cross-sectional analysis of VWH followed from 2014 to 2018 at the Michael E. DeBakey VA Medical Center Infectious Diseases Clinic, Houston, Texas. We collected data through registry extraction and chart review. We calculated the percentage of VWH with timely BMD loss screening by DXA within 5 years of turning 50. Secondary outcomes included prevalence of osteopenia, osteoporosis, and vitamin D deficiency. We included data from 1,243 VWH. Their average age was 52 years (range 18-86). Most were male (95%), and 59% were black. Of the 346 VWH who turned 50 years old during the study period, 78 (22.5%) underwent DXA within 5 years. Of these, 42 (53.8%) had normal BMD, 28 (35.9%) had osteopenia, and 8 (10.3%) had osteoporosis. Nine hundred ninety-three (79.9%) VWH had available 25-hydroxyvitamin D levels; of these, 453 (45%) had normal levels, 304 (30.6%) had vitamin D insufficiency, 184 (18.5%) had vitamin D deficiency, and 52 (5.2%) had severe vitamin D deficiency. Fewer than 25% of eligible VWH underwent timely BMD loss screening by DXA per IDSA guidelines. Almost half of screened VWH showed evidence of BMD loss. Although limited by lack of follow-up and fracture data, this study emphasizes the importance of improving BMD loss screening in this vulnerable population.

Veterans Aging Cohort Study Index as a Marker of Bone Disease in HIV-Infected Patients.

People living with human immunodeficiency virus (HIV) infection have higher risk of low bone mineral density (BMD) and fragility fracture than general population. The aim of our retrospective study was to explore if HIV-specific Veterans Aging Cohort Study (VACS) Index and its specific components could help identify patients at risk for low BMD. A total of 195 HIV-infected patients with dual-energy X-ray absorptiometry (DXA) scan between 2007 and 2014 were included and DXA scan results were used to classify patients with osteopenia. VACS Index was calculated for all patients using laboratory values closest to the date of DXA scan. Logistic regression was used to assess the association between VACS Index score or individual components of VACS Index with the presence of low BMD after adjusting for confounding variables. A total of 109 (56%) patients were diagnosed with low BMD. VACS Index score was significantly associated with low BMD, with the odds of low BMD increasing 1.21 times for each 10 unit increase in VACS Index score [confidence interval (95% CI) 1.03-1.42; p = .02]. The two groups differed significantly on patient weights, proportion of white patients, and hepatitis C-coinfected patients. After adjusting for white race and weight, hepatitis C coinfection was significantly associated with increased risk of low BMD (odds ratio 24.4; 95% CI 7.45-80.16). VACS Index score, previously demonstrated to be a marker of frailty in HIV-infected patients, is significantly associated with risk of low BMD and could be used to develop a prediction tool to screen for low BMD in resource-limited setting where DXA scans are not easily available.

One year survival of HIV-infected veterans with CD4 < 100 cells/mm3: data from a veteran cohort.

Survival among HIV-infected patients markedly improved with the introduction of highly active antiretroviral therapy (HAART). Easier to take and more effective HAART options have improved the one-year virologic success rate among naive patients. Numerous studies have shown that initiating HAART and restoration of CD4 cells positively impact survival. There are only a few evaluations that have been carried out on the changes in survival among patients who are severely immunosuppressed. We evaluated survival among a cohort of veterans with CD4<100 cells/mm(3) (CD4 < 100) in three time periods reflecting early, mid, and recent HAART. Using the HIV clinic database, all patients with CD4 < 100 seen between 1996 and 2004 were identified (n=394). Patients entered Cohorts 1 (n=219), 2 (n=72), and 3 (n=103) in 1996-1998, 1999-2001, and 2002-2004, respectively. Data on demographics, AIDS-defining illnesses, co-morbidities, treatment, CD4, and viral load (VL) were abstracted. Survival analysis controlling for the above variables was performed and odds ratios with 95% confidence intervals were calculated. Rate of virologic suppression was higher for Cohort 2 when compared to Cohort 1 (63% vs. 46%, p<0.05), but lower for Cohort 3 when compared to Cohort 2 (49%, p<0.05). Survival at one year was high for Cohorts 1 and 2 (92-95%), but significantly lower in Cohort 3 (80%). On logistic regression analysis and for the whole cohort, HAART use, achieving a CD4 > 200 and VL<400 were independent predictors of survival. Older age at cohort entry and having a diagnosis of lymphoma, Mycobacterium avium complex infection, coronary artery disease, or renal insufficiency were negative predictors. In the most recent HAART period 2002-2004, one year survival after CD4 < 100 significantly decreased in spite of availability of specialized HIV clinical and support services and antiretrovirals. Our results suggest that more than better drugs are needed for improving survival among certain patient populations with advanced immunosuppression.

Effect of combination antiretroviral treatment on total protein and calculated globulin levels among HIV-infected patients.

OBJECTIVES: Hypergammaglobulinemia is one of the manifestations of B-cell dysfunction associated with untreated HIV infection. Globulin levels are not routinely measured in HIV-infected patients on treatment. The purpose of this study was to evaluate the effect of highly active antiretroviral therapy (HAART) on calculated globulin levels. METHODS: The study group consisted of 75 HIV-infected treatment-naïve patients, starting HAART, and virologically suppressed for ≥6 months; 16 patients (21%) were HIV-HCV-co-infected. RESULTS: All patients experienced significant increases in CD4 cell counts at 6 and 12 months after HAART initiation compared to baseline (p<0.01 for all comparisons). The increase in CD4 cell counts was significant regardless of the HCV infection status. Significant increases in albumin levels (p<0.05 at 6 and 12 months), reductions in total protein (p<0.01 at 1 year; not significant at 6 months), and concomitant significant reductions in the calculated globulin levels (p<0.001 at 6 and 12 months) after HAART initiation compared to baseline were observed for the whole group. However, less than half the patients achieved a normal albumin/globulin ratio at 1 year. HIV-monoinfected patients had significant changes in albumin, total protein, and calculated globulin levels. In contrast, HIV-HCV-co-infected patients only showed significant increases in albumin levels. CONCLUSIONS: Future studies to evaluate the potential use of calculated globulin levels and albumin/globulin ratios as readily available surrogate markers of B-cell immune reconstitution in HIV-monoinfected patients are warranted.