The Impact of Antiretroviral Therapy in a Cohort of HIV Infected Patients Going in and out of the San Francisco County Jail

Background

Jails are an important venue of HIV care and a place for identification, treatment and referral for care. HIV infected inmates in the San Francisco County jail are offered antiretroviral treatment (ART), which many take only while in jail. We evaluated the effect of ART administration in a cohort of jail inmates going in and out of jail over a nine year period.

Methodology/Principal Findings

In this retrospective study, we examined inmates with HIV going in and out of jail. Inmates were categorized by patterns of ART use: continuous ART - ART both in and out of jail, intermittent ART - ART only in jail; never on ART - eligible by national guidelines, but refused ART. CD4 and HIV viral load (VL) were compared over time in these groups. Over a 9 year period, 512 inmates were studied: 388 (76%) on intermittent ART, 79 (15%) on continuous ART and 45(9%) never-on ART. In a linear mixed model analysis, inmates on intermittent ART were 1.43; 95%CI (1.03, 1.99) times and those never on ART were 2.89; 95%CI (1.71, 4.87) times more likely to have higher VL than inmates on continuous ART. Furthermore, Inmates on intermittent ART and never-on ART lost 1.60; 95%CI (1.06, 2.13) and 1.97; 95%CI (0.96, 3.00) more CD4 cells per month, respectively, compared to continuously treated inmates. The continuous ART inmates gained 0.67CD4 cells/month.

Conclusions/Significance

Continuous ART therapy in jail inmate''s benefits CD4 cell counts and control of VL especially compared to those who never took ART. Although jail inmates on intermittent ART were more likely to lose CD4 cells and experience higher VL over time than those on continuous ART, CD4 cell loss was slower in these inmates as compared to inmates never on ART. Further studies are needed to evaluate whether or not intermittent ART provides some benefit in outcome if continuous ART is not possible or likely.     

Assessing Risk-Based Policies for Pretrial Release and Split Sentencing in Los Angeles County Jails

Court-mandated downsizing of the CA prison system has led to a redistribution of detainees from prisons to CA county jails, and subsequent jail overcrowding. Using data that is representative of the LA County jail system, we build a mathematical model that tracks the flow of individuals during arraignment, pretrial release or detention, case disposition, jail sentence, and possible recidivism during pretrial release, after a failure to appear in court, during non-felony probation and during felony supervision. We assess 64 joint pretrial release and split-sentencing (where low-level felon sentences are split between jail time and mandatory supervision) policies that are based on the type of charge (felony or non-felony) and the risk category as determined by the CA Static Risk Assessment tool, and compare their performance to that of the policy LA County used in early 2014, before split sentencing was in use. In our model, policies that offer split sentences to all low-level felons optimize the key tradeoff between public safety and jail congestion by, e.g., simultaneously reducing the rearrest rate by 7% and the mean jail population by 20% relative to the policy LA County used in 2014. The effectiveness of split sentencing is due to two facts: (i) convicted felony offenders comprised ≈ 45% of LA County’s jail population in 2014, and (ii) compared to pretrial release, split sentencing exposes offenders to much less time under recidivism risk per saved jail day.     

Characteristics of the x-ray picture of pulmonary tuberculosis in alcoholics

Tuberculosis prevalence among alcoholics is high, and pathomorphological and clinical manifestations of the disease are marked. Altogether 84 chronic alcoholics with pulmonary tuberculosis (the 1st group) and 100 tuberculosis non-alcoholic patients (100 controls--the 2nd group) were investigated. X-ray signs of the disease progression, more prevalent changes and more frequent multiple disintegration cavity of larger size are noted in the 1st group. During x-ray investigation of such patients emphasis must be laid on a search for disintegration cavities and bronchogenic dissemination.     

Frequency of Strongyloides stercoralis infection in alcoholics

Several studies have shown that chronic alcoholics have increased susceptibility to infections due to higher exposure to infectious agents as well as breakdown in their immune defenses. As Strongyloides stercoralis infection is usually more relevant in immunocompromised patients, the aim of this study was to evaluate the frequency of S. stercoralis infection in alcoholics. Thus, coproparasitological examination was carried out in 145 subjects, from which 45 were chronic alcoholics (mean age of 45.7 +/- 11.0 years), 10 were nonalcoholic cirrhotic patients (mean age of 50.2 +/- 13.1 years), and 90 were asymptomatic nonalcoholic subjects (mean age of 46.7 +/- 10.1 years), which served as controls. From the alcoholics, 9 had hepatic cirrhosis, 9 had chronic pancreatitis and 27 had neither cirrhosis nor pancreatitis. For the diagnosis of strongyloidiasis, the Baermann-Moraes and Lutz methods were used in three fecal samples from each subject. Samples were collected at alternated days, and three slides of each sample were analyzed for each method, thus totalizing 2,610 slides examined. The frequency of strongloidiasis in the total alcoholic group (33.3%) and in the subgroups of alcoholics, i.e., patients with hepatic cirrhosis (44.4%), with chronic pancreatitis (33.3%), and those with no cirrhosis or pancreatitis (29.6%) was statistically higher than that found in the control group (5.5%). None of the individuals with nonalcoholic hepatic cirrhosis had S. stercoralis infection. Our results showed that the chronic alcoholism itself is an important factor that predisposes to strongyloidiasis.     

Failure of diagnosis as a factor in tuberculosis mortality.

In British Columbia between January 1970 and December 1974 active tuberculosis was diagnosed only after death in 69 cases; this was more frequent for miliary tuberculosis (31% of reported cases) than for advanced pulmonary tuberculosis (3% of cases). Although 28% of the patients were more than 75 years old, some were much younger, and 38% of the latter were alcoholics. More than 50% of the patients had been hospitalized before death, for a mean of 14.5 days; they were most frequently thought to have pneumonia or cancer at the time of death. Clearly, increased awareness of the continuing presence of tuberculosis in our society is needed.     

The Diagnostic Accuracy of Urine Lipoarabinomannan Test for Tuberculosis Screening in a South African Correctional Facility

Background

We evaluated the diagnostic accuracy of the urine lipoarabinomannan (LAM) antigen detection assay (Clearview TB-ELISA) to screen for tuberculosis in a South African correctional facility.

Methods

Between September 2009 and October 2010, male offenders were screened for tuberculosis (symptoms, chest radiograph, two spot sputum specimens for microscopy and culture), and urine tested for LAM. Sensitivity, specificity and predictive values of LAM were calculated using definite and probable tuberculosis combined as our gold standard.

Findings

33/871 (3.8%) participants (26% HIV-positive) had tuberculosis. Amongst HIV-positive vs. HIV-negative offenders the sensitivity and specificity of LAM was 7.1% vs. 0% and 98.5% vs. 99.8% respectively.

Conclusion

Urine LAM ELISA has inadequate sensitivity for TB screening in this population.     

Clastogenic effect of ethanol in chronic and abstinent alcoholics

Alcoholism is one of the main causes of damage for human health, being relevant to study the induction of chromosomal aberrations (CA) by ethanol, and to investigate the individual susceptibility to diseases caused by alcoholism. A cytogenetic study was performed in human peripheral blood lymphocytes of 29 heavy chronic alcoholics, 11 alcoholics in abstinence, and 10 controls. The values of the chromosomal aberrations, mitotic indexes (MI) and proliferation indexes (PI) were determined. A molecular cytogenetic study was also carried out using fluorescence in situ hybridization (FISH) method with DNA library probes for chromosomes 1, 3 and 6, in lymphocytes from chronic alcoholic individuals in comparison with a control group. The results showed that the CA frequencies for chronic alcoholics (5.15 CA/100 cells) and alcoholics in abstinence (3.87 CA/100 cells) were higher than those obtained for control individuals (1.72 CA/100 cells). The mean translocation frequencies (equivalent to the genome) were calculated for six chronic alcoholics (0.267 translocations/100 cells) and six alcoholics in abstinence (0.167 translocations/100 cells), whose values were significantly higher than those observed for six control individuals (0.067 translocations/100 cells). The CA frequencies were not statistically different when smoker and non-smoker alcoholics were compared, indicating that although the smoking habit had significantly increased (four-fold) the CA frequency in healthy control individuals, a lack of interaction effect was observed within the group of alcoholics when smokers and non-smokers were compared. The CA frequencies presented by alcoholics in abstinence were similar to those obtained for chronic alcoholics. Therefore, chronic ethanol intoxication can lead to chromosome damage and disturbances in the metabolism of endogenous and exogenous compounds, which may persist for a long time, and constitute a relevant factor of risk for the development of neoplasias.     

Clastogenic effect of ethanol in chronic and abstinent alcoholics

Alcoholism is one of the main causes of damage for human health, being relevant to study the induction of chromosomal aberrations (CA) by ethanol, and to investigate the individual susceptibility to diseases caused by alcoholism. A cytogenetic study was performed in human peripheral blood lymphocytes of 29 heavy chronic alcoholics, 11 alcoholics in abstinence, and 10 controls. The values of the chromosomal aberrations, mitotic indexes (MI) and proliferation indexes (PI) were determined. A molecular cytogenetic study was also carried out using fluorescence in situ hybridization (FISH) method with DNA library probes for chromosomes 1, 3 and 6, in lymphocytes from chronic alcoholic individuals in comparison with a control group. The results showed that the CA frequencies for chronic alcoholics (5.15 CA/100 cells) and alcoholics in abstinence (3.87 CA/100 cells) were higher than those obtained for control individuals (1.72 CA/100 cells). The mean translocation frequencies (equivalent to the genome) were calculated for six chronic alcoholics (0.267 translocations/100 cells) and six alcoholics in abstinence (0.167 translocations/100 cells), whose values were significantly higher than those observed for six control individuals (0.067 translocations/100 cells). The CA frequencies were not statistically different when smoker and non-smoker alcoholics were compared, indicating that although the smoking habit had significantly increased (four-fold) the CA frequency in healthy control individuals, a lack of interaction effect was observed within the group of alcoholics when smokers and non-smokers were compared. The CA frequencies presented by alcoholics in abstinence were similar to those obtained for chronic alcoholics. Therefore, chronic ethanol intoxication can lead to chromosome damage and disturbances in the metabolism of endogenous and exogenous compounds, which may persist for a long time, and constitute a relevant factor of risk for the development of neoplasias.     

Antibodies to morphine and neuromediators in the blood serum of chronic alcoholics

The data on the presence of antibodies to morphine and neurotransmitters (dopamine, norepinephrine, serotonin) in the blood serum of chronic alcoholics are presented. The antibodies were detected by the modification of complement-fixation test. 82% of chronic alcoholics showed significantly elevated levels (P less than 0.01) of antibodies to morphine (5.34 +/- 0.65% of complement fixed) when compared to the control group (2.41 +/- 0.52% of complement fixed), which was an indirect evidence of the presence of endogenous morphine-like compounds in men and their role in the pathogenesis of the disease. A general group of alcoholics could be divided into subgroups with significantly elevated and decreased levels of antibodies to the appropriate neurotransmitter, as compared to the control group, which significantly differed from each other. Similar results were obtained in chronically alcoholized rats.     

Alcoholism in Tuberculous Patients

The incidence of alcoholism among patients suffering from tuberculosis in the Tuberculosis Hospital in Winnipeg was determined, and attention is drawn to the need to treat tuberculosis and alcoholism concurrently. In all, 306 patients with tuberculosis were studied and 32 alcoholics were discovered among them. This frequency is five times that estimated in the adult population of Canada. Ninety-two per cent of these alcoholics were addicted before the tuberculous disease was discovered. No direct causative factor was discovered linking alcoholism and tuberculosis. Poor socioeconomic status appears to be a common etiological factor.     

Drug injection and HIV prevalence in inmates of Glenochil prison.

OBJECTIVE--To determine prevalence of HIV infection and drug injecting behaviour among inmates of Glenochil Prison on a specified date a year after an outbreak of hepatitis B and HIV infection. DESIGN--Cross sectional: voluntary, anonymous HIV salivary antibody surveillance and linked self completion questionnaire on risk factors. SETTING--Glenochil prison, Scotland, a year after an outbreak of hepatitis B and HIV transmission related to drug injection. SUBJECTS--352 prisoners, of whom 295 (84%) took part; 284 questionnaires (96%) passed logical checks. MAIN OUTCOME MEASURES--HIV prevalence; proportion of all inmates who had ever injected drugs, had ever injected inside prison, had started injecting drugs while inside prison. RESULTS--More than half (150/284) the current inmates were also in Glenochil Prison during the critical period of January to June 1993, when hepatitis B and HIV were transmitted. Similar proportions of current inmates and men who were also in Glenochil during the critical period were drug users (27% (75/278) v 30% (44/149)). A quarter of injecting drug users (18/72) had first injected inside prison, irrespective of whether they were in Glenochil in January to June 1993 and regardless of the calendar period when they first injected. Significantly more inmates from Glasgow (41%; 56/138) than from Edinburgh (21%; 7/34) or elsewhere (11%; 12/106) were injecting drug users. On testing for HIV, seven saliva samples out of 293 gave positive results--four were presumed to be from inmates known to be infected with HIV, and the others from injecting drug users from Glasgow, all of whom had been in Glenochil during January to June 1993, when two of the three had injected drugs and had been tested for HIV, with negative results. The ratio of overall (2.4%) to disclosed (1.4%) HIV prevalence was 1.7. For men who had injected drugs in Glenochil during January to June 1993, HIV prevalence was estimated at 29%. CONCLUSION--Between a quarter and a third of prisoners who injected drugs in Glenochil in January to June 1993 were infected with HIV. There is widespread ongoing risk of bloodborne virus infection within prisons, which is probably long standing but demands urgent attention.     

The metabolic response to exercise in chronic alcoholics

The metabolic response to steady exercise was studied in six chronic alcoholics and six normal control subjects. Higher concentrations of lactated and pyruvate were observed in the alcoholics during exercise and they also developed post-exercise ketosis. These changes were probably not due to reduced fitness of the alcoholics as the heart rates of both groups were similar. Alcoholics had lower levels of growth hormone during exercise compared with the controls suggesting that chronic alcohol consumption has a depressor effect on pathways regulating the release of growth hormone.     

Ethanol-responsive gene expression in neural cell cultures.

We have studied the molecular mechanisms underlying neuronal adaptation to chronic ethanol exposure. NG108-15 neuroblastoma cells were used to perform a detailed analysis of ethanol-induced changes in neuronal gene expression. High resolution, quantitative two-dimensional (2-D) gel electrophoresis of in vitro translation products showed both dose-dependent increases and decreases in specific mRNA abundance following treatment with ethanol at concentrations seen in actively drinking alcoholics (50-200 mM). Dose response curves for representative members of the increasing or decreasing response groups had very similar profiles, suggesting that similar mechanisms may regulate members of a response group. Some mRNAs that increased with ethanol treatment appeared identical to species induced by heat shock while other mRNAs were only induced by ethanol. We conclude that chronic ethanol exposure can produce specific coordinate changes in expression of neuronal mRNAs, including some members of the stress protein response. However, the overall pattern of ethanol-responsive gene expression is distinct from the classical heat shock subgroup of stress proteins response. Changes in gene expression and specifically, mechanisms regulating a subset of stress protein expression, could be an important aspect of neuronal adaptation to chronic ethanol seen in alcoholics.     

The influence of host and bacterial genotype on the development of disseminated disease with Mycobacterium tuberculosis

The factors that govern the development of tuberculosis disease are incompletely understood. We hypothesized that some strains of Mycobacterium tuberculosis (M. tuberculosis) are more capable of causing disseminated disease than others and may be associated with polymorphisms in host genes responsible for the innate immune response to infection. We compared the host and bacterial genotype in 187 Vietnamese adults with tuberculous meningitis (TBM) and 237 Vietnamese adults with uncomplicated pulmonary tuberculosis. The host genotype of tuberculosis cases was also compared with the genotype of 392 cord blood controls from the same population. Isolates of M. tuberculosis were genotyped by large sequence polymorphisms. The hosts were defined by polymorphisms in genes encoding Toll-interleukin 1 receptor domain containing adaptor protein (TIRAP) and Toll-like receptor-2 (TLR-2). We found a significant protective association between the Euro-American lineage of M. tuberculosis and pulmonary rather than meningeal tuberculosis (Odds ratio (OR) for causing TBM 0.395, 95% confidence intervals (C.I.) 0.193-0.806, P = 0.009), suggesting these strains are less capable of extra-pulmonary dissemination than others in the study population. We also found that individuals with the C allele of TLR-2 T597C allele were more likely to have tuberculosis caused by the East-Asian/Beijing genotype (OR = 1.57 [95% C.I. 1.15-2.15]) than other individuals. The study provides evidence that M. tuberculosis genotype influences clinical disease phenotype and demonstrates, for the first time, a significant interaction between host and bacterial genotypes and the development of tuberculosis.     

Colonic microbiome is altered in alcoholism

Several studies indicate the importance of colonic microbiota in metabolic and inflammatory disorders and importance of diet on microbiota composition. The effects of alcohol, one of the prominent components of diet, on colonic bacterial composition is largely unknown. Mounting evidence suggests that gut-derived bacterial endotoxins are cofactors for alcohol-induced tissue injury and organ failure like alcoholic liver disease (ALD) that only occur in a subset of alcoholics. We hypothesized that chronic alcohol consumption results in alterations of the gut microbiome in a subgroup of alcoholics, and this may be responsible for the observed inflammatory state and endotoxemia in alcoholics. Thus we interrogated the mucosa-associated colonic microbiome in 48 alcoholics with and without ALD as well as 18 healthy subjects. Colonic biopsy samples from subjects were analyzed for microbiota composition using length heterogeneity PCR fingerprinting and multitag pyrosequencing. A subgroup of alcoholics have an altered colonic microbiome (dysbiosis). The alcoholics with dysbiosis had lower median abundances of Bacteroidetes and higher ones of Proteobacteria. The observed alterations appear to correlate with high levels of serum endotoxin in a subset of the samples. Network topology analysis indicated that alcohol use is correlated with decreased connectivity of the microbial network, and this alteration is seen even after an extended period of sobriety. We show that the colonic mucosa-associated bacterial microbiome is altered in a subset of alcoholics. The altered microbiota composition is persistent and correlates with endotoxemia in a subgroup of alcoholics.     

Extra Y chromosomes and alcoholism

Summary The authors examined the karyotype of 89 out of the 102 men 180 cm (511) tall or more among the 459 male inmates of four Swedish institutions for alcoholics. All 89 had a normal chromosome constitution.     

Antiretroviral outcomes in South African prisoners: a retrospective cohort analysis

Background and Methods

Little is known about antiretroviral therapy (ART) outcomes in prisoners in Africa. We conducted a retrospective review of outcomes of a large cohort of prisoners referred to a public sector, urban HIV clinic. The review included baseline characteristics, sequential CD4 cell counts and viral load results, complications and co-morbidities, mortality and loss to follow-up up to 96 weeks on ART.

Findings

148 inmates (133 male) initiated on ART were included in the study. By week 96 on ART, 73% of all inmates enrolled in the study and 92% of those still accessing care had an undetectable viral load (<400copies/ml). The median CD4 cell count increased from 122 cells/mm³ at baseline to 356 cells/mm³ by 96 weeks. By study end, 96 (65%) inmates had ever received tuberculosis (TB) therapy with 63 (43%) receiving therapy during the study: 28% had a history of TB prior to ART initiation, 33% were on TB therapy at ART initiation and 22% developed TB whilst on ART. Nine (6%) inmates died, 7 in the second year on ART. Loss to follow-up (LTF) was common: 14 (9%) patients were LTF whilst still incarcerated, 11 (7%) were LTF post-release and 9 (6%) whose movements could not be traced. 16 (11%) inmates had inter-correctional facility transfers and 34 (23%) were released of whom only 23 (68%) returned to the ART clinic for ongoing follow-up.

Conclusions

Inmates responded well to ART, despite a high frequency of TB/HIV co-infection. Attention should be directed towards ensuring eligible prisoners access ART programs promptly and that inter-facility transfers and release procedures facilitate continuity of care. Institutional TB control measures should remain a priority.     

Outbreak of HIV infection in a Scottish prison.

OBJECTIVE--To investigate the possible spread of HIV infection and its route of transmission among prison inmates. DESIGN--In response to an outbreak of acute clinical hepatitis B and two seroconversions to HIV infection, counselling and testing for HIV were offered to all inmates over a two week period in July 1993. Information was sought about drug injecting, sexual behaviour, and previous HIV testing. SETTING--HM Prison Glenochil in Scotland. SUBJECTS--Adult male prisoners. MAIN OUTCOME MEASURES--Uptake of HIV counselling and testing; occurrence and mode of HIV transmission within the prison. RESULTS--Of a total 378 inmates, 227 (60%) were counselled and 162 (43%) tested for HIV. Twelve (7%) of those tested were positive for antibody to HIV. One third (76) of those counselled had injected drugs at some time, of whom 33 (43%) had injected in Glenochil; all 12 seropositive men belonged to this latter group. Thirty two of these 33 had shared needles and syringes in the prison. A further two inmates who injected in the prison were diagnosed as positive for HIV two months previously. Evidence based on sequential results and time of entry into prison indicated that eight transmissions definitely occurred within prison in the first half of 1993. CONCLUSION--This is the first report of an outbreak of HIV infection occurring within a prison. Restricted access to injecting equipment resulted in random sharing and placed injectors at high risk of becoming infected with HIV. Measures to prevent further spread of infection among prison injectors are urgently required.     

Blood glucose in intoxicated chronic alcoholics.

Chronic alcoholics may present with hyperglycemia or hypoglycemia. Because alcohol induces glycogenolysis, chronic alcoholics usually have higher blood glucose values than do nonalcoholic subjects. In a prospective study of blood glucose concentration in 201 chronic alcoholics, blood alcohol concentration, sex, weight, type of beverage consumed and time since last eating were not generally associated with lower blood glucose values. The infrequency of hypoglycemia in ambulatory chronic alcoholics may reflect the relatively ready availability of hostels, detoxification centres and hospitals in large cities. It is, however, important to be aware of the possible occurrence of hypoglycemia in chronic alcoholics, particularly when community facilities for the chronic alcoholic are not available.     

Alcoholism and substance abuse among selected southern cheyenne Indians

This family and small community-based study reports the occurrence of alcoholism and co-occurring substance abuse in Southern Cheyenne Indians living in western Oklahoma. Sociocultural factors complicate operationalization of clinical data into standard (DSM-III-R) psychiatric disorder terminology; understanding sociocultural factors is essential for assessing the high rate of addictive disorders in this group. To obtain reliable and valid clinical diagnoses, data from several sources were utilized within a blind rating system: 1) SADS-L, a clinician-administered research diagnostic instrument; 2) MAST; 3) relatives; 4) medical records; 5) other official documents. The sample consisted of 69 males (45 alcoholics) and 97 females (36 alcoholics). Among clinically significant substance abusers (moderate impairment of function), 22 of 24 were alcoholics. In non-alcoholics, mean MAST scores were 8.8 (males) and 5.1 (females); in alcoholics, 32.0 (males) and 38.7 (females). Mean age of onset on heavy use of alcohol was 20.1 yrs. (males) and 22.8 (females) (p = 0.047); among all alcoholics, 86% (males) and 64% (females) had early onset (< 25 yrs. old). When data from 98 unrelated subjects were analyzed separately, similar findings were observed except that mean age of onset of heavy use of alcohol was more discrepant between males and females, viz. 20.1 versus 22.8 yrs. (p = 0.02). Among those with substance abuse disorders, early age of onset was present in all but one female. In these Cheyenne, alcoholism is usually clinically severe and early in onset; it often co-occurs with substance abuse, also early in onset.