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JAMA The Journal of the American Medical Association
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     ISSN (Print) 0098-7484 - ISSN (Online) 1538-3598
     Published by American Medical Association Homepage  [11 journals]   [SJR: 4.843]   [H-I: 456]
  • Medications to Prevent HIV Infection
    • Authors: Jin J.
      PubDate: Wed, 23 Jul 2014 00:00:00 GMT
  • JAMA
    • PubDate: Wed, 23 Jul 2014 00:00:00 GMT
  • Milk May Delay Knee Osteoarthritis in Women
    • Authors: Slomski A.
      Abstract: Frequently drinking fat-free or low-fat milk may slow the progression of osteoarthritis of the knee in women but not men, according to a prospective study of 1260 women and 888 men (Lu B et al. Arthritis Care Res. doi:10.1002/acr.22297 [published online May 27, 2014]).
      PubDate: Wed, 23 Jul 2014 00:00:00 GMT
  • The Washington Post/Kaiser Family Foundation Survey of Iraq and
           Afghanistan Active Duty Soldiers and Veterans
    • Authors: ; DiJulio B, Brodie M, et al.
      PubDate: Wed, 23 Jul 2014 00:00:00 GMT
  • Clinician’s Guide for Genomics
    • Authors: Kuehn BM.
      Abstract: The number of physicians ordering genome or exome testing for their patients is expected to increase from several thousand this year to 10 000 next year, with continued growth thereafter, according to National Human Genome Research Institute’s Leslie G. Biesecker, MD. Because uptake of this new technology is increasing, Biesecker and Robert C. Green, MD, MPH, of Harvard Medical School, have published a primer to help clinicians implement these technologies (Biesecker LG and Green RC. N Engl J Med. 2014;370[25]:2418-2425).
      PubDate: Wed, 23 Jul 2014 00:00:00 GMT
  • ED Visits for Sedatives Increase
    • Authors: Kuehn BM.
      Abstract: Emergency department (ED) visits involving misuse of the sedative alprazolam doubled between 2005 and 2010, according to a new report from the Substance Abuse and Mental Health Services Administration (SAMHSA).
      PubDate: Wed, 23 Jul 2014 00:00:00 GMT
  • FDA Opens Adverse Event Data
    • Authors: Kuehn BM.
      Abstract: The US Food and Drug Administration (FDA) has launched a new initiative to make it easier for researchers, web developers, and others to access and build interactive tools based the FDA’s Adverse Events Reporting System data.
      PubDate: Wed, 23 Jul 2014 00:00:00 GMT
  • FDA Sets Social Media Rules
    • Authors: Kuehn BM.
      Abstract: The US Food and Drug Administration (FDA) released its long-awaited guidance for marketing via social media in June.
      PubDate: Wed, 23 Jul 2014 00:00:00 GMT
  • Spoils of Wild Game Hunt: Trichinellosis Cases in Illinois
    • Abstract: Wild boar meat was the likely cause of 9 trichinellosis cases diagnosed last year in Cook County, Illinois.
      PubDate: Wed, 23 Jul 2014 00:00:00 GMT
  • Zika Virus Strikes French Polynesia
    • Abstract: Investigations spanning the archipelagoes of French Polynesia in late 2013 documented the largest outbreak of Zika virus, public health researchers have reported.
      PubDate: Wed, 23 Jul 2014 00:00:00 GMT
  • Woman With Child Pablo Picasso
    • Authors: Smith JM.
      PubDate: Wed, 23 Jul 2014 00:00:00 GMT
  • Found in the Street
    • Authors: Bronson R.
      Abstract: You were dead drunk, smelling of piss,swollen toes bursting maggot-filled socks,legs a mottled sea of cellulitis.
      PubDate: Wed, 23 Jul 2014 00:00:00 GMT
  • Screening Test for HTLV-III (AIDS Agent) Antibodies Specificity,
           Sensitivity, and Applications
    • Authors: Weiss SH; Goedert JJ, Sarngadharan MG, et al.
      Abstract: The third member of the family of human T-cell leukemia (lymphotropic) retroviruses, HTLV-III, has emerged as the likely etiologic agent of the acquired immunodeficiency syndrome (AIDS). There is a recognized need for a serological assay for HTLV-III that could be used for epidemiologic studies and screening of defined populations. Ideally, such a test would be reproducible, specific, sensitive, relatively inexpensive, timely, and noninvasive.…
      PubDate: Wed, 23 Jul 2014 00:00:00 GMT
  • Highlights
    • PubDate: Wed, 23 Jul 2014 00:00:00 GMT
  • An HIV Cure Feasibility, Discovery, and Implementation
    • Authors: Fauci AS; Marston HD, Folkers GK.
      Abstract: The discovery and deployment of antiretroviral therapy (ART) for human immunodeficiency virus (HIV) infection is one of the most extraordinary achievements in recent biomedical history. Between 1996 and 2012, ART averted an estimated 6.6 million AIDS-related deaths worldwide. For HIV-infected individuals with access to ART, life expectancy at diagnosis now approximates that of uninfected individuals—a remarkable feat. These extraordinary successes, however, are tempered by the necessity of lifelong drug therapy. Many patients struggle with adherence in the face of competing priorities, both within the clinical context (comorbidities) and beyond (food insecurity, housing, substance abuse, and other challenges). The drugs can cause health issues in the form of cumulative toxicities. Nations and health systems struggle to find the resources needed to provide long-term therapy. The challenges of resistance and drug-drug interactions add considerable complexity to the provision of care.
      PubDate: Wed, 23 Jul 2014 00:00:00 GMT
  • Reconsideration of the Lifetime Ban on Blood Donation by Men Who Have Sex
           With Men
    • Authors: Cohen I; Feigenbaum J, Adashi EY.
      Abstract: In 2013, the US Supreme Court took a historic step in United States v Windsor by striking down the Defense of Marriage Act on the grounds that it imposed a “disability on the class [of gay Americans] by refusing to acknowledge a status the State finds to be dignified and proper.” This milestone in gay rights stands in stark contrast to the ongoing lifetime ban imposed in 1983 on blood donation by men who have ever had sex with men (MSMs) even once. As it stands, the US Food and Drug Administration (FDA) continues to uphold this 30-year-old policy, unaltered, on the grounds that MSMs remain at increased risk of contracting transfusion-transmissible pathogens such as human immunodeficiency virus (HIV).
      PubDate: Wed, 23 Jul 2014 00:00:00 GMT
  • Realization of an AIDS-Free Generation Ensuring Sustainable Treatment for
    • Authors: Heidari S; Mofenson LM, Bekker L.
      Abstract: According to a 2011 statement from the Joint United Nations Program on HIV/AIDS (UNAIDS), “by 2015 children everywhere can be born free of HIV and their mothers remain alive.” These ambitious goals were defined to provide renewed energy and to reinvigorate programs to realize the vision of an AIDS-free generation. Since the launch of the Global Plan Toward the Elimination of New HIV Infections Among Children by 2015 and Keeping Their Mothers Alive (focused on 22 countries with the highest estimated numbers of pregnant women, with a goal to reduce new HIV infection by 90% and HIV-related maternal deaths by 5%), there has been a substantive expansion of investments resulting in improved access to antiretroviral therapy (ART) in pregnant women as a means to eliminate vertical HIV transmission. As a result, at the end of 2012, 62% of pregnant women with HIV in low- and middle-income countries were receiving ART for prevention of vertical transmission, a significant increase from 14% in 2005. This progress has led to a reduction of new infections among children; between 2009 and 2012, it is estimated that 670 000 children in these countries were prevented from acquiring HIV infection.
      PubDate: Wed, 23 Jul 2014 00:00:00 GMT
  • Maximizing Benefits of New Strategies to Prevent Mother-to-Child HIV
           Transmission Without Harming Existing Services
    • Authors: Chi BH; Thirumurthy H, Stringer JA.
      Abstract: Over the past decade, global efforts to prevent mother-to-child human immunodeficiency virus (HIV) transmission have been driven by rapid progress in scientific discovery, policy, and program implementation. One important advance has been the Option B+ strategy to provide lifelong antiretroviral therapy (ART) to all HIV-infected women identified during pregnancy or breastfeeding. Initially developed as a strategy for settings in which CD4 T-lymphocyte testing was not available, Option B+ is now endorsed by the World Health Organization and and its implementation has expanded to other countries worldwide. Although there are many clinical and operational justifications for the strategy, successful implementation of Option B+ requires substantial new investments in health infrastructure. Concerns that introduction of ambitious new services may redirect already scarce resources away from other initiatives are legitimate and warrant a careful evaluation and policy response.
      PubDate: Wed, 23 Jul 2014 00:00:00 GMT
  • From JAMA’s Daily News Site
    • PubDate: Wed, 23 Jul 2014 00:00:00 GMT
  • Antidepressants in Pregnancy Don’t Lead to Cardiac Defects in
    • Authors: Slomski A.
      Abstract: Antidepressant use during the first trimester of pregnancy is not associated with an increased risk of congenital cardiac malformations in infants, according to results of a cohort study of 949 504 women in the Medicaid program (Huybrechts K et al. N Engl J Med. 2014;370[25]:2397-2407). The study refutes previous studies that have found an association between paroxetine use and right ventricular outflow tract obstruction and between sertraline use and ventricular septal defects.
      PubDate: Wed, 23 Jul 2014 00:00:00 GMT
  • Ketamine Effective in Treating PTSD
    • Authors: Slomski A.
      Abstract: A single dose of ketamine given in an intravenous (IV) infusion resulted in the rapid reduction of symptoms of posttraumatic stress disorder (PTSD) in a proof-of-concept, randomized, double-blind study of 41 patients with chronic PTSD (Feder A et al. JAMA Psychiatry. 2014;71[6]:681-688).
      PubDate: Wed, 23 Jul 2014 00:00:00 GMT
  • Lower Blood Pressure Not Necessarily Better
    • Authors: Slomski A.
      Abstract: Although previous studies have found that heart disease risk progressively increases as blood pressure rises above 115/75 mm Hg, lowering systolic blood pressure below 120 mm Hg in adults with hypertension did not reduce the rate of myocardial infarction, coronary heart disease, heart failure, and ischemic stroke in an observational study (Rodriguez C et al. JAMA Intern Med. doi:10.1001/jamainternmed.2014.2482 [published online June 16, 2014]).
      PubDate: Wed, 23 Jul 2014 00:00:00 GMT
  • Early Descriptions of Closed-Chest Cardiac Massage—Reply
    • Authors: Eisenberg MS; Bobrow BJ, Rea T.
      Abstract: In Reply Dr Shiber references the early literature of cardiopulmonary resuscitation. There were indeed several descriptions of maneuvers that were similar to closed-chest compression as practiced today. Some of these early techniques were in fact designed to help ventilate the lungs rather than circulate blood. The 1960 article by Kouwenhoven et al was the first human clinical application based on animal experimentation with unequivocal utility in a prospectively observed case series. It was a landmark study and in a very short time dramatically changed the management of cardiac arrest.
      PubDate: Wed, 23 Jul 2014 00:00:00 GMT
  • Gene Researchers Work to Engineer HIV-Resistant Cells
    • Authors: Hampton T.
      Abstract: Ever since the evolution of the HIV/AIDS pandemic, researchers have long sought effective strategies to prevent HIV infection or help the body keep the virus in check after infection has occurred. In addition to a decades-long effort to develop an effective vaccine and continuing research to find less toxic drugs, some researchers are focusing on another strategy—modifying the genes of host cells to make them resistant to infection.
      PubDate: Wed, 23 Jul 2014 00:00:00 GMT
  • Physicians’ Group Discourages Routine Pelvic Examination
    • Authors: Kuehn BM.
      Abstract: Most women are accustomed to the uncomfortable ritual of having a yearly pelvic examination. But a new guideline from the American College of Physicians (ACP) suggests it may be time to make the procedure a thing of the past for women without any symptoms of concern (Qaseem A et al. Ann Intern Med. 2014;161[1]:67-72). The recommendation does not apply to pregnant women or those who have signs of illness.
      PubDate: Wed, 23 Jul 2014 00:00:00 GMT
  • Liver Transplants Among US Veterans—Reply
    • Authors: Kaplan DE; Goldberg DS.
      Abstract: In Reply We concur with Dr Gunnar that distance-related inequities in access to liver transplantation are not unique to the VHA. However, the absence of robust national databases precludes such evaluations in the non-VA population. The VHA’s integrated electronic medical record allowed us to use the VHA as a model of the effects of centralization and there was no intent to imply that these are VHA-specific disparities. Unlike private centers, the VHA attempts to minimize the additional burden of distance by providing travel assistance to veterans and caregivers; however, such support does not ameliorate the reduced access to transplantation for veterans living more than 100 miles from a VATC.
      PubDate: Wed, 23 Jul 2014 00:00:00 GMT
  • Early Descriptions of Closed-Chest Cardiac Massage
    • Authors: Shiber J.
      Abstract: To the Editor In their recent Viewpoint, Dr Eisenberg and colleagues stated that “closed-chest cardiac massage for the treatment of cardiac arrest was first described in the medical literature in 1960.” There had been descriptions of closed-chest cardiac massage as well as cases of its application among human patients published more than 50 years prior to that date. The first accurate description of external cardiac compressions by sternal compression for resuscitation of cardiac arrest was by Hill in 1868: “The surgeon’s left hand was placed firmly across the front of the chest, the fingers resting over the fifth, sixth, and seventh cartilages on the right side, while the tip of the thumb lay on the second piece of the sternum and the muscular part of the hand on the corresponding cartilages on the left side. The right hand now crossed over the left and forcible pressure made; the hands then being suddenly removed, the chest was allowed to expand by its own elasticity.”
      PubDate: Wed, 23 Jul 2014 00:00:00 GMT
  • Liver Transplants Among US Veterans
    • Authors: Gunnar WP.
      Abstract: To the Editor Dr Goldberg and colleagues reported a disparity in the rates of US veterans waitlisted for liver transplantation and, once waitlisted, receiving a liver transplant when the veteran’s local Veteran’s Affairs (VA) medical center was located more than 100 miles from a transplant center. This disparity was observed regardless of whether the veteran received care at a Veterans Affairs Transplant Center (VATC) or a non-VATC. I believe that the authors imply that distance relationships affect veterans more so than similarly situated nonveterans and this requires clarification.
      PubDate: Wed, 23 Jul 2014 00:00:00 GMT
  • Evaluating a Multipayer Medical Home Intervention
    • Authors: Boone J; Boone EA.
      Abstract: To the Editor We participated in the southwestern Pennsylvania version of the PACCI and achieved level 3 NCQA PCMH recognition. Contrary to the findings of Dr Friedberg and colleagues, our practice did find a significant decrease in low-density lipoprotein cholesterol and systolic blood pressure levels in 126 patients with diabetes who were aged 18 to 75 years over the 18-month period from 2009 to 2011, when we achieved level 3 PCMH recognition. However, no change was noted in high-density lipoprotein cholesterol levels, diastolic blood pressure, and coronary heart disease risk scores. Hemoglobin A1c levels decreased 1 percentage point on average.
      PubDate: Wed, 23 Jul 2014 00:00:00 GMT
  • Evaluating a Multipayer Medical Home Intervention—Reply
    • Authors: Friedberg MW; Schneider EC, Werner RM.
      Abstract: In Reply Drs Valko and Wender suggest that a 3-year time horizon may be too short to observe changes in health care costs and utilization, reporting that in their medical home practice these changes occurred later. It is certainly possible that reducing costs and excess health care utilization may require sustained changes and longer observation periods. Continued evaluations are needed.
      PubDate: Wed, 23 Jul 2014 00:00:00 GMT
  • Evaluating a Multipayer Medical Home Intervention
    • Authors: Valko G; Wender R.
      Abstract: To the Editor As physicians involved in the Pennsylvania Chronic Care Initiative (PACCI), a medical home pilot, we are concerned that the evaluation of the first phase had many inadequacies that steered Dr Friedberg and colleagues to the wrong conclusions. These conclusions have the potential to impede further payment reform and block continued redesign of primary care practices.
      PubDate: Wed, 23 Jul 2014 00:00:00 GMT
  • Evaluating a Multipayer Medical Home Intervention
    • Authors: Cronholm PF; Miller-Day M, Gabbay R.
      Abstract: To the Editor Dr Friedberg and colleagues analyzed a multipayer medical home intervention and failed to demonstrate meaningful outcomes. We performed a rigorous mixed-methods evaluation of the same PACCI through on-site observations and interviewing 118 individuals (clinicians, staff, and administrators) at 17 of the 25 participating primary care practices in the PACCI. We believe our evaluation provides important insights into the challenges of translating the PACCI into meaningful outcomes.
      PubDate: Wed, 23 Jul 2014 00:00:00 GMT
  • Recurrent Erythema Multiforme
    • Authors: Levin J; Hofstra T.
      PubDate: Wed, 23 Jul 2014 00:00:00 GMT
  • Dolutegravir (Tivicay) for HIV
    • Abstract: The FDA has approved dolutegravir (doll-you-TEG-rah-veer; Tivicay – Viiv Healthcare), an integrase strand transfer inhibitor (INSTI), for treatment of HIV-1 infection in adults and in children ≥12 years old who weigh at least 40 kg. It is the third INSTI to be approved by the FDA; raltegravir and elvitegravir were approved earlier (Table 1).
      PubDate: Wed, 23 Jul 2014 00:00:00 GMT
  • Trends in Diagnoses of HIV Infection in the United States, 2002-2011
    • Authors: Johnson A; Hall H, Hu X, et al.
      Abstract: There has been increasing emphasis on care and treatment for persons with human immunodeficiency virus (HIV) in the United States during the past decade, including the use of antiretroviral therapy for increasing survival and decreasing transmission. Accurate HIV diagnosis data recently became available for all states, allowing for the first time an examination of long-term national trends. These data can be used to monitor awareness of serostatus among persons living with HIV, primary prevention efforts, and testing initiatives. We examined trends in HIV diagnoses from 2002-2011 in the United States using data from the National HIV Surveillance System of the US Centers for Disease Control and Prevention (CDC).
      PubDate: Wed, 23 Jul 2014 00:00:00 GMT
  • Antiretroviral Treatment of Adult HIV Infection 2014 Recommendations of
           the International Antiviral Society–USA Panel
    • Authors: Günthard HF; Aberg JA, Eron JJ, et al.
      Abstract: ImportanceNew data and antiretroviral regimens expand treatment choices in resource-rich settings and warrant an update of recommendations to treat adults infected with human immunodeficiency virus (HIV).ObjectiveTo provide updated treatment recommendations for adults with HIV, emphasizing when to start treatment; what treatment to start; the use of laboratory monitoring tools; and managing treatment failure, switches, and simplification.Data Sources, Study Selection, and Data SynthesisAn International Antiviral Society–USA panel of experts in HIV research and patient care considered previous data and reviewed new data since the 2012 update with literature searches in PubMed and EMBASE through June 2014. Recommendations and ratings were based on the quality of evidence and consensus.ResultsAntiretroviral therapy is recommended for all adults with HIV infection. Evidence for benefits of treatment and quality of available data increase at lower CD4 cell counts. Recommended initial regimens include 2 nucleoside reverse transcriptase inhibitors (NRTIs; abacavir/lamivudine or tenofovir disoproxil fumarate/emtricitabine) and a third single or boosted drug, which should be an integrase strand transfer inhibitor (dolutegravir, elvitegravir, or raltegravir), a nonnucleoside reverse transcriptase inhibitor (efavirenz or rilpivirine) or a boosted protease inhibitor (darunavir or atazanavir). Alternative regimens are available. Boosted protease inhibitor monotherapy is generally not recommended, but NRTI-sparing approaches may be considered. New guidance for optimal timing of monitoring of laboratory parameters is provided. Suspected treatment failure warrants rapid confirmation, performance of resistance testing while the patient is receiving the failing regimen, and evaluation of reasons for failure before consideration of switching therapy. Regimen switches for adverse effects, convenience, or to reduce costs should not jeopardize antiretroviral potency.Conclusions and RelevanceAfter confirmed diagnosis of HIV infection, antiretroviral therapy should be initiated in all individuals who are willing and ready to start treatment. Regimens should be selected or changed based on resistance test results with consideration of dosing frequency, pill burden, adverse toxic effect profiles, comorbidities, and drug interactions.
      PubDate: Wed, 23 Jul 2014 00:00:00 GMT
  • HIV Prevention in Clinical Care Settings 2014 Recommendations of the
           International Antiviral Society–USA Panel
    • Authors: Marrazzo JM; del Rio C, Holtgrave DR, et al.
      Abstract: ImportanceEmerging data warrant the integration of biomedical and behavioral recommendations for human immunodeficiency virus (HIV) prevention in clinical care settings.ObjectiveTo provide current recommendations for the prevention of HIV infection in adults and adolescents for integration in clinical care settings.Data Sources, Study Selection, and Data SynthesisData published or presented as abstracts at scientific conferences (past 17 years) were systematically searched and reviewed by the International Antiviral (formerly AIDS) Society—USA HIV Prevention Recommendations Panel. Panel members supplied additional relevant publications, reviewed available data, and formed recommendations by full-panel consensus.ResultsTesting for HIV is recommended at least once for all adults and adolescents, with repeated testing for those at increased risk of acquiring HIV. Clinicians should be alert to the possibility of acute HIV infection and promptly pursue diagnostic testing if suspected. At diagnosis of HIV, all individuals should be linked to care for timely initiation of antiretroviral therapy (ART). Support for adherence and retention in care, individualized risk assessment and counseling, assistance with partner notification, and periodic screening for common sexually transmitted infections (STIs) is recommended for HIV-infected individuals as part of care. In HIV-uninfected patients, those persons at high risk of HIV infection should be prioritized for delivery of interventions such as preexposure prophylaxis and individualized counseling on risk reduction. Daily emtricitabine/tenofovir disoproxil fumarate is recommended as preexposure prophylaxis for persons at high risk for HIV based on background incidence or recent diagnosis of incident STIs, use of injection drugs or shared needles, or recent use of nonoccupational postexposure prophylaxis; ongoing use of preexposure prophylaxis should be guided by regular risk assessment. For persons who inject drugs, harm reduction services should be provided (needle and syringe exchange programs, supervised injection, and available medically assisted therapies, including opioid agonists and antagonists); low-threshold detoxification and drug cessation programs should be made available. Postexposure prophylaxis is recommended for all persons who have sustained a mucosal or parenteral exposure to HIV from a known infected source and should be initiated as soon as possible.Conclusions and RelevanceData support the integration of biomedical and behavioral approaches for prevention of HIV infection in clinical care settings. A concerted effort to implement combination strategies for HIV prevention is needed to realize the goal of an AIDS-free generation.
      PubDate: Wed, 23 Jul 2014 00:00:00 GMT
  • Effect of Tesamorelin on Visceral Fat and Liver Fat in HIV-Infected
           Patients With Abdominal Fat Accumulation A Randomized Clinical Trial
    • Authors: Stanley TL; Feldpausch MN, Oh J, et al.
      Abstract: ImportanceAmong patients infected with human immunodeficiency virus (HIV), visceral adiposity is associated with metabolic dysregulation and ectopic fat accumulation. Tesamorelin, a growth hormone–releasing hormone analog, specifically targets visceral fat reduction but its effects on liver fat are unknown.ObjectiveTo investigate the effect of tesamorelin on visceral and liver fat.Design, Setting, and PatientsDouble-blind, randomized, placebo-controlled trial conducted among 50 antiretroviral-treated HIV-infected men and women with abdominal fat accumulation at Massachusetts General Hospital in Boston. The first patient was enrolled on January 10, 2011; for the final patient, the 6-month study visit was completed on September 6, 2013.InterventionsParticipants were randomized to receive tesamorelin, 2 mg (n=28), or placebo (n=22), subcutaneously daily for 6 months.Main Outcomes and MeasuresPrimary end points were changes in visceral adipose tissue and liver fat. Secondary end points included glucose levels and other metabolic end points.ResultsForty-eight patients received treatment with study drug. Tesamorelin significantly reduced visceral adipose tissue (mean change, –34 cm2 [95% CI, –53 to –15 cm2] with tesamorelin vs 8 cm2 [95% CI, –14 to 30 cm2] with placebo; treatment effect, –42 cm2 [95% CI, –71 to –14 cm2]; P = .005) and liver fat (median change in lipid to water percentage, –2.0% [interquartile range {IQR}, –6.4% to 0.1%] with tesamorelin vs 0.9% [IQR, –0.6% to 3.7%] with placebo; P = .003) over 6 months, for a net treatment effect of –2.9% in lipid to water percentage. Fasting glucose increased in the tesamorelin group at 2 weeks (mean change, 9 mg/dL [95% CI, 5-13 mg/dL] vs 2 mg/dL [95% CI, –3 to 8 mg/dL] in the placebo group; treatment effect, 7 mg/dL [95% CI, 1-14 mg/dL]; P = .03), but changes at 6 months in fasting glucose (mean change, 4 mg/dL [95% CI, –2 to 10 mg/dL] with tesamorelin vs 2 mg/dL [95% CI, –4 to 7 mg/dL] with placebo; treatment effect, 2 mg/dL [95% CI, –6 to 10 mg/dL]; P = .72 overall across time points) and 2-hour glucose (mean change, –1 mg/dL [95% CI, –18 to 15 mg/dL] vs –8 mg/dL [95% CI, –24 to 8 mg/dL], respectively; treatment effect, 7 mg/dL [95% CI, –16 to 29 mg/dL]; P = .53 overall across time points) were not significant.Conclusions and RelevanceIn this preliminary study of HIV-infected patients with abdominal fat accumulation, tesamorelin administered for 6 months was associated with reductions in visceral fat and additionally with modest reductions in liver fat. Further studies are needed to determine the clinical importance and long-term consequences of these findings.Trial Identifier: NCT01263717
      PubDate: Wed, 23 Jul 2014 00:00:00 GMT
  • Effect of Optional Home Initiation of HIV Care Following HIV Self-testing
           on Antiretroviral Therapy Initiation Among Adults in Malawi A Randomized
           Clinical Trial
    • Authors: MacPherson P; Lalloo DG, Webb EL, et al.
      Abstract: ImportanceSelf-testing for HIV infection may contribute to early diagnosis of HIV, but without necessarily increasing antiretroviral therapy (ART) initiation.ObjectiveTo investigate whether offering optional home initiation of HIV care after HIV self-testing might increase demand for ART initiation, compared with HIV self-testing accompanied by facility-based services only.Design, Setting, and ParticipantsCluster randomized trial conducted in Blantyre, Malawi, between January 30 and November 5, 2012, using restricted 1:1 randomization of 14 community health worker catchment areas. Participants were all adult (≥16 years) residents (n = 16 660) who received access to home HIV self-testing through resident volunteers. This was a second-stage randomization of clusters allocated to the HIV self-testing group of a parent trial.InterventionsClusters were randomly allocated to facility-based care or optional home initiation of HIV care (including 2 weeks of ART if eligible) for participants reporting positive HIV self-test results.Main Outcomes and MeasuresThe preplanned primary outcome compared between groups the proportion of all adult residents who initiated ART within the first 6 months of HIV self-testing availability. Secondary outcomes were uptake of HIV self-testing, reporting of positive HIV self-test results, and rates of loss from ART at 6 months.ResultsA significantly greater proportion of adults in the home group initiated ART (181/8194, 2.2%) compared with the facility group (63/8466, 0.7%; risk ratio [RR], 2.94, 95% CI, 2.10-4.12; P 
      PubDate: Wed, 23 Jul 2014 00:00:00 GMT
  • Pregnancy Incidence and Outcomes Among Women Receiving Preexposure
           Prophylaxis for HIV Prevention A Randomized Clinical Trial
    • Authors: Mugo NR; Hong T, Celum C, et al.
      Abstract: ImportanceAntiretroviral preexposure prophylaxis (PrEP), using tenofovir disoproxil fumarate (TDF) and combination emtricitabine/tenofovir disoproxil fumarate (FTC+TDF), is efficacious for prevention of human immunodeficiency virus (HIV) acquisition. PrEP could reduce periconception HIV risk, but the effect on pregnancy outcomes is not well defined.ObjectiveTo assess pregnancy incidence and outcomes among women using PrEP during the periconception period.Design, Setting, and ParticipantsRandomized trial among 1785 HIV-serodiscordant heterosexual couples (the Partners PrEP Study) in which the female partner was HIV uninfected that demonstrated that PrEP was efficacious for HIV prevention, conducted between July 2008 and June 2013 at 9 sites in Kenya and Uganda.InterventionsDaily oral TDF (n = 598), combination FTC+TDF (n = 566), or placebo (n = 621) through July 2011, when PrEP demonstrated efficacy for HIV prevention. Thereafter, participants continued receiving active PrEP without placebo. Pregnancy testing occurred monthly and study medication was discontinued when pregnancy was detected.Main Outcomes and MeasuresPregnancy incidence, birth outcomes (live births, pregnancy loss, preterm birth, congenital anomalies), and infant growth.ResultsA total of 431 pregnancies occurred. Pregnancy incidence was 10.0 per 100 person-years among women assigned placebo, 11.9 among those assigned TDF (incidence difference, 1.9; 95% CI, −1.1 to 4.9 [P = .22 vs placebo]), and 8.8 among those assigned FTC+TDF (incidence difference, −1.3; 95% CI, −4.1 to 1.5 [P = .39 vs placebo]). Before discontinuation of the placebo treatment group in July 2011, the occurrence of pregnancy loss (96 of 288 pregnancies) was 42.5% for women receiving FTC+TDF compared with 32.3% for those receiving placebo (difference for FTC+TDF vs placebo, 10.2%; 95% CI, −5.3% to 25.7%; P = .16) and was 27.7% for those receiving TDF alone (difference vs placebo, −4.6%; 95% CI, −18.1% to 8.9%; P = .46). After July 2011, the frequency of pregnancy loss (52 of 143 pregnancies) was 37.5% for FTC+TDF and 36.7% for TDF alone (difference, 0.8%; 95% CI, −16.8% to 18.5%; P = .92). Occurrence of preterm birth, congenital anomalies, and growth throughout the first year of life did not differ significantly for infants born to women who received PrEP vs placebo. Conclusions and RelevanceAmong HIV-serodiscordant heterosexual African couples, differences in pregnancy incidence, birth outcomes, and infant growth were not statistically different for women receiving PrEP with TDF alone or combination FTC+TDF compared with placebo at conception. Given that PrEP was discontinued when pregnancy was detected and that CIs for the birth outcomes were wide, definitive statements about the safety of PrEP in the periconception period cannot be made. These results should be discussed with HIV-uninfected women receiving PrEP who are considering becoming pregnant.Trial Identifier: NCT00557245
      PubDate: Wed, 23 Jul 2014 00:00:00 GMT
  • Integrating HIV Prevention Into Practice
    • Authors: Mathers BM; Cooper DA.
      Abstract: At the beginning of the human immunodeficiency virus (HIV) epidemic 30 years ago, the main methods for prevention were clean needles and condoms. Even though these available methods would work, their success was completely dependent on human behavior. However, over the past decade, biomedical prevention of HIV has come of age, in the wake of the extraordinary success of antiretroviral therapy (ART) for treatment of the HIV-infected person. In quick succession, effective approaches for prevention were developed and implemented, including prevention of mother-to-child HIV transmission through birth and breastfeeding, medical male circumcision, preexposure prophylaxis (PrEP), vaginal microbicides, and prevention of transmission to uninfected partners of an HIV-infected person with effective ART.
      PubDate: Wed, 23 Jul 2014 00:00:00 GMT
  • HIV/AIDS: Gaining Ground and Forging Forward
    • Authors: Smith JM.
      Abstract: The physician and scientist Galen (born in the second century) endeavored to consider all possible implications when pondering a problem. “Reason,” he wrote, “finds the answers most quickly, but experience confirms our confidence in them.”
      PubDate: Wed, 23 Jul 2014 00:00:00 GMT
  • Sofosbuvir and Ribavirin for Hepatitis C in Patients With HIV Coinfection
    • Authors: Sulkowski MS; Naggie S, Lalezari J, et al.
      Abstract: ImportanceTreatment of hepatitis C virus (HCV) infection in patients also infected with human immunodeficiency virus (HIV) has been limited due to drug interactions with antiretroviral therapies (ARTs) and the need to use interferon. ObjectiveTo determine the rates of HCV eradication (sustained virologic response [SVR]) and adverse events in patients with HCV-HIV coinfection receiving sofosbuvir and ribavirin treatment.Design, Setting, and ParticipantsOpen-label, nonrandomized, uncontrolled phase 3 trial conducted at 34 treatment centers in the United States and Puerto Rico (August 2012-November 2013) evaluating treatment with sofosbuvir and ribavirin among patients with HCV genotypes 1, 2, or 3 and concurrent HIV. Patients were required to be receiving ART with HIV RNA values of 50 copies/mL or less and a CD4 T-cell count of more than 200 cells/μL or to have untreated HIV infection with a CD4 T-cell count of more than 500 cells/μL. Of the treatment-naive patients, 114 had HCV genotype 1 and 68 had HCV genotype 2 or 3, and 41 treatment experienced participants who had been treated with peginterferon-ribavirin had HCV genotype 2 or 3, for a total of 223 participants.InterventionsTreatment-naive patients with HCV genotype 2 or 3 received 400 mg of sofosbuvir and weight-based ribavirin for 12 weeks and treatment-naive patients with HCV genotype 1 and treatment-experienced patients with HCV genotype 2 or 3 received the same treatment for 24 weeks.Main Outcomes and MeasuresThe primary study outcome was the proportion of patients with SVR (serum HCV
      PubDate: Wed, 23 Jul 2014 00:00:00 GMT
  • Water, Water, Everywhere
    • Authors: Farel CE.
      Abstract: “Doc, they’re not giving me my Benadryl.” The patient scraped his long fingernails along his neck to emphasize the point, his skin falling in tiny flakes onto his dark green uniform. The space where he used to have eyebrows lifted quizzically, awaiting my response.
      PubDate: Wed, 23 Jul 2014 00:00:00 GMT
  • Pause, Listen, Share
    • Authors: Cantrell KA; Sutton S, Gaur AH.
      PubDate: Wed, 23 Jul 2014 00:00:00 GMT
  • Quantum Leaps, Microeconomics, and the Treatment of Patients With
           Hepatitis C and HIV Coinfection
    • Authors: Saag MS.
      Abstract: Until very recently, patients with hepatitis C virus (HCV) infection were treated with pegylated-interferon administered weekly by subcutaneous injection plus ribavirin given orally twice daily. Over the last decade, however, by virtue of development of directly acting agents, therapy for hepatitis C infection has advanced by several orders of magnitude, creating a transformative and unprecedented revolution.
      PubDate: Wed, 23 Jul 2014 00:00:00 GMT
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