Calculating Age-Standardized Death Rates Among People With HIV Comparable Across Jurisdictions and Over Time.

The Centers for Disease Control and Prevention (CDC) and local health jurisdictions have been using HIV surveillance data to monitor mortality among people with HIV in the United States with age-standardized death rates, but the principles of age standardization have not been consistently followed, making age standardization lose its purpose-comparison over time, across jurisdictions, or by other characteristics.We review the current practices of age standardization in calculating death rates among people with HIV in the United States, discuss the principles of age standardization including those specific to the HIV population whose age distribution differs markedly from that of the US 2000 standard population, make recommendations, and report age-standardized death rates among people with HIV in New York City.When we restricted the analysis population to adults aged between 18 and 84 years in New York City, the age-standardized death rate among people with HIV decreased from 20.8 per 1000 (95% confidence interval [CI] = 19.2, 22.3) in 2013 to 17.1 per 1000 (95% CI = 15.8, 18.3) in 2017, and the age-standardized death rate among people without HIV decreased from 5.8 per 1000 in 2013 to 5.5 per 1000 in 2017.

Brief Report: Drug Overdose Deaths Among People With HIV in New York City, 2007-2017.

BACKGROUND: Preventable deaths, including those because of drug overdose (OD), are a significant public health concern in New York City (NYC). Trends in drug OD death among people with HIV (PWH) in NYC have not been described. METHODS: We selected PWH from the NYC HIV Registry who died during 2007-2017, resided in NYC at death, and died because of drug OD. We characterized PWH who died of drug OD and analyzed CD4 and viral load tests from surveillance to evaluate retention in care and viral suppression (viral load < 200 cc/mL) in the 12 months before death as markers of care-seeking. RESULTS: From 2007 to 2017, 870 NYC PWH died of drug OD. Of the total OD deaths, 821 (94.4%) were classified as accidental and 49 (5.6%) as intentional. Although the rate of OD deaths among PWH declined during the full period, from 58.5 per 100,000 in 2007 to 47.9 per 100,000 in 2017, it increased from 2014 (30.9/100,000) to 2016 (53.3/100,000) and stayed high through 2017 (47.9/100,000). Decedents during 2007-2017 were predominantly men (70.8%), Black (38.0%) or Latino/Hispanic (38.7%), aged 40-59 years (73.2%), and had a history of injection drug use (43.0%). Over 3-quarters (80.1%) of decedents were retained in HIV care in the 12 months preceding death; 45.4% were viral suppression. CONCLUSIONS: A sizeable number of PWH died of OD during 2007-2017, and OD death rates in recent years increased. Predeath care patterns reveal frequent interaction with the health care system, underscoring missed opportunities for harm-reduction and suicide prevention interventions for PWH.

Sex- and Poverty-Specific Patterns in Cardiovascular Disease Mortality Associated With Human Immunodeficiency Virus, New York City, 2007-2017.

BACKGROUND: Human immunodeficiency virus (HIV) may affect the risk of death due to cardiovascular disease (CVD) differently in men versus women. METHODS: We examined CVD mortality rates between 2007 and 2017 among all New York City residents living with HIV and aged 13+ by sex, using data from city HIV surveillance and vital statistics and the National Death Index. Residents without HIV were enumerated using modified US intercensal estimates. We determined associations of HIV status with CVD mortality by sex and neighborhood poverty, defined as the percent of residents living below the federal poverty level, after accounting for age, race/ethnicity, and year. RESULTS: There were 3234 CVD deaths reported among 147 915 New Yorkers living with HIV, with the proportion of deaths due to CVD increasing from 11% in 2007 to 22% in 2017. The age-standardized CVD mortality rate was 2.7/1000 person-years among both men and women with HIV. The relative rate of CVD mortality associated with HIV status was significantly higher among women (adjusted rate ratio [aRR] 1.7, 95% confidence interval [CI] 1.6-1.8) than men (aRR 1.2, 95% CI 1.1-1.3) overall, and within strata defined by neighborhood poverty. Sex differences in CVD mortality rates were the greatest when comparing individuals living with HIV and having detectable HIV RNA and CD4+ T-cell counts <500 cells/uL with individuals living without HIV. CONCLUSIONS: Among people with HIV, 1 in 5 deaths is now associated with CVD. HIV providers should recognize the CVD risk among women with HIV, and reinforce preventive measures (eg, smoking cessation, blood pressure control, lipid management) and viremic control among people living with HIV regardless of neighborhood poverty to reduce CVD mortality.Human immunodeficiency virus (HIV) increases cardiovascular disease mortality risks to a greater degree among women than men, even after accounting for neighborhood poverty. HIV providers should emphasize cardiovascular disease prevention (eg, smoking cessation, hypertension control, lipid management) and viremic control.

Linking HIV and Viral Hepatitis Surveillance Data: Evaluating a Standard, Deterministic Matching Algorithm Using Data From 6 US Health Jurisdictions.

Accurate interpretations and comparisons of record linkage results across jurisdictions require valid and reliable matching methods. We compared existing matching methods used by 6 US state and local health departments (Houston, Texas; Louisiana; Michigan; New York, New York; North Dakota; and Wisconsin) to link human immunodeficiency virus and viral hepatitis surveillance data with a 14-key automated, hierarchical deterministic matching method. Applicable years of study varied by disease and jurisdiction, ranging from 1979 to 2016. We calculated percentage agreement and Cohen's κ coefficient to compare the matching methods used within each jurisdiction. We calculated sensitivity, specificity, and positive predictive value for each matching method, as compared with a new standard that included manual review of discrepant cases. Agreement between the existing matching method and the deterministic matching method was 99.6% or higher in all jurisdictions; Cohen's κ values ranged from 0.87 to 0.98. The sensitivity of the deterministic matching method ranged from 97.4% to 100% in the 6 jurisdictions; specificity ranged from 99.7% to 100%; and positive predictive value ranged from 97.4% to 100%. Although no gold standard exists, prior assessments of existing methods and review of discrepant classifications suggest good accuracy and reliability of our deterministic matching method, with the advantage that our method reduces the need for manual review and allows for standard comparisons across jurisdictions when linking human immunodeficiency virus and viral hepatitis data.

Transition from paediatric to adult care among persons with perinatal HIV infection in New York City, 2006-2015.

OBJECTIVE: The aim of this study was to evaluate the transition process from paediatric to adult care among persons with perinatal HIV infection in New York City (NYC). DESIGN: A retrospective prepost study and a matched exposed/unexposed nested cohort study. METHODS: Using data from the NYC HIV registry, a retrospective prepost study was performed among persons who transitioned from paediatric to adult care to assess pre and posttransition retention in care (≥1 CD4 cell count/viral load in a 12-month period), CD4 cell count and viral suppression (≤200 copies/ml). A 1 : 3 matched exposed/unexposed nested cohort study was conducted to assess pre and posttransition 1-year mortality by matching persons who transitioned to adult care and persons who remained in paediatric care on calendar year (±1 year) and age at transition (±1 year). RESULTS: A total of 735 persons with perinatal HIV infection transitioned to adult care in NYC during 2006-2015, of whom 53.9% were women, 57.7% black and 37.1% Hispanic. Pretransition (Year 0), and posttransition Year 1, Year 2 and Year 3 proportions of persons with CD4 cell count at least 500 cells/µl were 35.2, 38.3, 38.9 and 39.0%, respectively, and viral suppression were 45.9, 48.6, 51.1 and 51.8%, respectively. One-year mortality rates before and after transition were 2.3/1000 and 55.8/1000, respectively. CONCLUSION: Persons with perinatal HIV infection in NYC who transitioned from paediatric to adult care saw improvements in CD4 cell count and viral suppression after transition. The increase in mortality after transition was likely caused by the conditions before or leading to the transition.

Trends in Cardiovascular Disease Mortality Among Persons With HIV in New York City, 2001-2012.

BACKGROUND: Cardiovascular disease (CVD) has become more prominent among human immunodeficiency virus (HIV)-infected individuals. The extent to which CVD mortality rates are changing is unclear. METHODS: We analyzed surveillance data for all persons aged ≥13 years with HIV infection between 2001 and 2012 reported to the New York City HIV Surveillance Registry. We examined age-specific and age-standardized mortality rates due to major CVDs. We compared mortality time trends among persons with HIV with the general population, and examined differences among HIV-infected persons by RNA level. RESULTS: There were 29 588 deaths reported among 145 845 HIV-infected persons. Ten percent of deaths were attributed to CVD as the underlying cause, including chronic ischemic heart disease (42% of CVD deaths), hypertensive diseases (27%), and cerebrovascular diseases (10%). While proportionate mortality due to CVD among persons with HIV increased (6% in 2001 to 15% in 2012, P < .001), the CVD mortality rate decreased from 5.1 to 2.7 per 1000 person-years. After controlling for sex, race/ethnicity, borough of residence, and year, those with HIV had significantly higher CVD mortality than the general population in all age groups through age 65. The CVD mortality rate was highest among viremic persons (adjusted rate ratio [RR], 3.53 [95% confidence interval {CI}, 3.21-3.87]) but still elevated among virally suppressed (<400 copies/mL) persons (adjusted RR, 1.53 [95% CI, 1.41-1.66]) compared with the general population. CONCLUSIONS: Our findings support continued emphasis by HIV care providers on both viremic control and preventive measures including smoking cessation, blood pressure control, and lipid management.

Human Immunodeficiency Virus Infection Newly Diagnosed at Autopsy in New York City, 2008-2012.

Background. Studying the most extreme example of late diagnosis, new HIV diagnoses after death, may be instructive to HIV testing efforts. Using the results of routine HIV testing of autopsies performed by the Office of Chief Medical Examiner (OCME), we identified new HIV diagnoses after death in New York City (NYC) from 2008 to 2012. Methods. Population-based registries for HIV and deaths were linked to identify decedents not known to be HIV-infected before death. Multivariable logistic regression models were constructed to determine correlates of a new HIV diagnosis after death among all persons newly diagnosed with HIV and among all HIV-infected decedents receiving an OCME autopsy. Results. Of 264 893 deaths, 24 426 (9.2%) were autopsied by the NYC OCME. Of these, 1623 (6.6%) were infected with HIV, including 142 (8.8%) with a new HIV diagnosis at autopsy. This represents 0.8% (142 of 18 542) of all new HIV diagnoses during the 5-year period. Decedents newly diagnosed with HIV at OCME autopsy were predominantly male (73.9%), aged 13-64 years (85.9%), non-white (85.2%), unmarried (81.7%), less than college educated (83.8%), and residents of an impoverished neighborhood (62.0%). Of all HIV-infected OCME decedents aged ≥65 years (n = 71), 22.0% were diagnosed at autopsy. The strongest independent correlate of new HIV diagnosis at autopsy in both multivariable models was age ≥65 years. Conclusions. Human immunodeficiency virus diagnoses first made after death are rare, but, when observed, these diagnoses are more commonly found among persons ≥65 years, suggesting that despite highly visible efforts to promote HIV testing community-wide, timely diagnosis among older adults living in impoverished, high-prevalence neighborhoods may require additional strategies.

Estimation of HIV prevalence, risk factors, and testing frequency among sexually active men who have sex with men, aged 18-64 years--New York City, 2002.

Population-based estimates of human immunodeficiency virus (HIV) prevalence and risk behaviors among men who have sex with men (MSM) are valuable for HIV prevention planning but not widely available, especially at the local level. We combined two population-based data sources to estimate prevalence of diagnosed HIV infection, HIV-associated risk-behaviors, and HIV testing patterns among sexually active MSM in New York City (NYC). HIV/AIDS surveillance data were used to determine the number of living males reporting a history of sex with men who had been diagnosed in NYC with HIV infection through 2002 (23% of HIV-infected males did not have HIV transmission risk information available). Sexual behavior data from a cross-sectional telephone survey were used to estimate the number of sexually active MSM in NYC in 2002. Prevalence of diagnosed HIV infection was estimated using the ratio of HIV-infected MSM to sexually active MSM. The estimated base prevalence of diagnosed HIV infection was 8.4% overall (95% confidence interval [CI] = 7.5-9.6). Diagnosed HIV prevalence was highest among MSM who were non-Hispanic black (12.6%, 95% CI = 9.8-17.6), aged 35-44 (12.6%, 95% CI = 10.4-15.9), or 45-54 years (13.1%, 95% CI = 10.2-18.3), and residents of Manhattan (17.7%, 95% CI = 14.5-22.8). Overall, 37% (95% CI = 32-43%) of MSM reported using a condom at last sex, and 34% (95% CI = 28-39%) reported being tested for HIV in the past year. Estimates derived through sensitivity analyses (assigning a range of HIV-infected males with no reported risk information as MSM) yielded higher diagnosed HIV prevalence estimates (11.0-13.2%). Accounting for additional undiagnosed HIV-infected MSM yielded even higher prevalence estimates. The high prevalence of diagnosed HIV among sexually active MSM in NYC is likely due to a combination of high incidence over the course of the epidemic and prolonged survival in the era of highly active antiretroviral therapy. Despite high HIV prevalence in this population, condom use and HIV testing are low. Combining complementary population-based data sources can provide critical HIV-related information to guide prevention efforts. Individual counseling and education interventions should focus on increasing condom use and encouraging safer sex practices among all sexually active MSM, particularly those groups with low levels of condom use and multiple sex partners.

Estimates of HIV incidence among persons testing for HIV using the sensitive/less sensitive enzyme immunoassy, New York City, 2001.

BACKGROUND: Estimates of the incidence of HIV infection among persons testing for HIV can be derived by applying a newly available serologic test to the diagnostic specimen of HIV-positive persons. Such estimates would enhance the targeting of HIV prevention resources and provide a sensitive outcome measure for prevention program evaluation. The goal of this investigation was to estimate the incidence of HIV infection among persons testing for HIV in New York City. METHODS: The study population consisted of persons testing for HIV in public settings in New York City during 2001 (n = 114,703). We applied a less sensitive enzyme immunoassay (LS-EIA) (Vironostika, BioMerieux, Durham, NC) to the diagnostic blood specimen of 1022 persons in whom HIV (non-AIDS) had been diagnosed for the first time in 2001. The distribution of transmission risk among HIV-negative persons--men who have sex with men (MSM), injection drug users (IDUs), heterosexuals-from a large telephone health survey was used to generate denominators for transmission risk groups. RESULTS: The 1022 persons tested by the LS-EIA represented 27% of all persons in whom HIV (non-AIDS) had been diagnosed in New York City during 2001. The incidence of HIV was estimated to be 0.29% per year (95% CI: 0.20-0.38), and was significantly higher for men than women (rate ratio 3.6, 95% CI: 2.6-5.1), and HIV incidence increased with age. Male IDU and MSM testers had the highest HIV incidence rates: 2.7% per year (95% CI: 2.3-3.1) and 2.5% per year (95% CI: 2.1-2.8), respectively. CONCLUSIONS: Male IDUs and MSM may be good candidates for intensified targeting of HIV prevention resources in New York City.

Efficacy of ketorolac in lieu of narcotics in the operative management of laparoscopic surgery for morbid obesity.

BACKGROUND: Prompt recovery of protective airway reflexes, freedom from pain, ability to cooperate with respiratory physical therapy, early ambulation and discharge from the postanesthesia care unit (PACU), coupled with a stable intraoperative environment have been desired goals of anesthesia management of morbidly obese patients. We used ketorolac in lieu of narcotics toward this goal and present our subjective and objective data in this study. METHODS: A total of 50 morbidly obese patients undergoing laparoscopic gastric bypass surgery were randomly assigned to 2 groups of 25 each. Group I received intravenous ketorolac perioperatively, which was continued 24 hours postoperatively. Group II received remifentanyl intraoperatively as a part of balanced anesthesia. Intraoperative hemodynamic stability was assessed based on blood pressure, pulse rate, and bispectral index score values. Postoperative pain intensity using a visual analogue scale, as well as the presence of nausea, vomiting, hypotension, or respiratory depression, were also recorded. RESULTS: Postoperative side effects, including pain, nausea, and vomiting; requirements for analgesics and antiemetic medications in the PACU; and the time spent in the PACU varied significantly between the 2 groups. Continued administration of ketorolac during the first 24 hours postoperatively led to improved patient satisfaction and more enthusiastic participation in respiratory physical therapy. CONCLUSIONS: Perioperative use of intravenous ketorolac up to 24 hours after laparoscopic gastric bypass surgery for morbid obesity helps provide a more stable intraoperative environment, earlier discharge from the PACU, and better outcome in this subset of patients.