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The havacs cohort description.doc
The HAVACS (HIV Atlanta VA Cohort Study)
was initiated in 1982 to clinically care for and
study all HIV+ veterans seeking care at the Atlanta VA Medical Center. To date, over 3,000
patients have been entered into this cohort and database. The prospective collection of data
was begun in 1982 and includes the full HIV history of patients including any care they received
for their HIV disease before receiving care at the AVAMC. The database provides the
physicians and other health care providers with an individual’s summary of current pertinent
patient information. Additionally, this database is used for surveillance and research analyses
and aids in the identification of patients eligible for research protocols. The Veterans Affairs
(VA) population is unique in that these patients are likely to receive all treatment and care in the
VA system. Only 1.8% have been lost to follow-up since 1982. Therefore, unlike many large
clinical and research databases, loss to follow-up or missing clinical information is not a source
Information collected on standardized forms includes demographic characteristics, clinical symptoms, HIV-related diagnoses, prophylaxes, antiretroviral regimens, vaccinations, inpatient visits and diagnoses and laboratory measurements. These data are updated for every patient contact with the AVAMC including inpatient and clinic visits. Pharmaceutical data are also collected from the computerized pharmacy database. All data are kept in a secured and centralized database. If the patient has left care from the VA system, outcome data are collected from active sources such as family members and passive sources such as National Death Index and the National Veterans Benefits Database. The database is routinely checked for quality of data during other analyses and routine use of the patient summary sheets.
The patient population is 99% male, 69% African American, 29.5% Caucasian and 1.5% Hispanic. MSM is the primary risk factor for 50% of the cohort; IV drug abuse accounts for an additional 19% and heterosexual contact 4% of the HIV risk factor. Twenty-two percent of the patients are naïve to antiretrovirals; 30.7% were naïve before starting HAART. Co-infection with hepatitis C is common with 35% of the cohort being dual infected. Mean age is 47 years.
Multiple studies recently have been published from the HAVACS database. These studies include two recent manuscripts on the impact of hepatitis C coinfection on survival, adverse events of protease inhibitors and response of HIV+ patients to hepatitis A vaccine. Most recently, Drs. Guest and Rimland have been part of a Department of Health and Human Services grant entitled “Protease inhibitor-induced hyperlipidemia in AIDS” that has resulted in two manuscripts to date. In these cross-sectional studies of both men and women, both protease inhibitors and non-nucleoside reverse transcriptase inhibitors were found to be associated with elevated apolipoproteins, specifically apoc-III. In the women, an additional association was found with elevated total cholesterol level that was not seen with the men. However, an elevation was seen in triglyceride levels for the men but not the women. These data add to the growing evidence of gender-related differences in the natural history, pharmacokinetics and toxicity of antiretroviral therapy.
A subset of patients from HAVACS are currently enrolled in VACS (n=500), SMART, OPTIMA, and FRAM 1 and 2.
Dr. David Rimland is the Chief of Infectious Disease at the Atlanta VA Medical Center and a Professor of Medicine at Emory University. Dr. Jodie L. Guest is the Director of HIV Research at the Atlanta VA Medical Center and holds adjunct associate professor positions at the Rollins School of Public Health and the School of Medicine, both at Emory University. Both can be reached at 1670 Clairmont Rd, Mailstop 111-RIM, Decatur, GA, 30033, USA. Dr. Guest’s email address is . Dr. Rimland’s email address is
1. Stroud L, Srivastava P, Culver D, Bisno A, Rimland D, et al: Nosocomial infections in HIV-infected patients:
preliminary results from a multicenter surveillance system (1989-1995). Inf Control and Hospital Epidemiol
, 1997; 18:479-485.
2. Stuyver L, Wyseur A, Rombout A, Louwagie J, Scarcez T, Verhofstede C, Rimland D, Schinazi RF, Rossau R:
Line probe assay (LiPA) for the rapid detection of drug-selected mutations in the HIV-1 reverse transcriptase gene. Antimicrob Agents Chemother
, 1997; 41:284-291.
3. Ward TT, Rimland D, Kauffman C, Huycke M, Evans TG and Heifetz L: Randomized, open label trial of
azithromycin plus ethambutol versus clarithromycin plus ethambutol therapy of Mycobacterium avium complex bacteremia in patients with human immunodeficiency virus infection. Clin Inf Dis
4. Staples CT, Rimland D, Dudas D: Hepatitis C in HIV Atlanta VA Cohort Study (HAVACS): The effect of co-
infection on survival. Clin Inf Dis
5. Edge MD, Rimland D: Reasons for failure of prophylaxis for Pneumocystis carinii pneumonia. AIDS
6. Navin TR, Rimland D, Lennox JL, Jernigan J, Cetron M, Hightower A, Roberts JM, Kaplan J: Risk factors for
community-acquired pneumonia among persons infected with human immunodeficiency virus. J Inf Dis
7. Chapman LE, Green TA, Parekh BS, Ahmed F, Rimland D, Kaplan JE, Thompson M, Folks TM. Effect of
clinical events on plasma HIV-1 RNA levels in individuals with CD4 above 500. AIDS
8. Nicholson JKA, Browning SW, Hengel RL, Lew E, Gallagher LE, Rimland D, McDougal JS. CCR5 and CXCR4
expression on memory and naïve T cells in HIV-1 infection and response to highly active antiretroviral therapy. JAIDS
9. Lew E, Gallagher L, Kuehnert M, Rimland D, Hubbard M, Parekh B, Zell E, Jarvis W, Jason J. Intracellular
cytokines in the acute response to highly active antiretroviral therapy. AIDS
10. Lasker BA, Elie CM, Lott TJ, Espinel-Ingroff A, Gallagher L, Kuykend-Kellum ME, Pruitt WR, Warnock DW,
Rimland D, McNeill MM, Reiss E. Molecular epidemiology of Candida albicans strains isolated from the oropharynx of HIV-positive patients at successive clinic visits. Med Mycology
11. Paddock C, Folk SM, Shore GM, Machado LJ, Huycke MM, Slater LN, Liddell AM, Buller RS, Storch GA,
Monson TM, Rimland D et al. Infections with Ehrlichia chaffeensis and Ehrlichia ewingii in persons coinfected with human immunodeficiency virus. Clin Inf Dis
12. Rimland D, Navin TR, Lennox J, Jernigan J, Kaplan J, Erdman D et al: Prospective study of etiologic agents of
community-acquired pneumonia in patients with HIV infection. AIDS
13. Cannon MJ, Dollard SC, Black JB, Edlin BR, Hannah C, Hogan SE, Patel MM, Jaffee HW, Offermann MK,
Spira TJ, Pellett PE, Gunthel CJ. Risk factors for Kaposi’s sarcoma in men seropositive for both human herpesvirus 8 and human immunodeficiency virus. AIDS
14. Justice AC, McGinnis KA, Atkinson JH, Heaton R, Young C, Sadek J, Madenwald T, Becker JT, Conigliaro J,
Brown ST, Rimland D, Crystal S, Simberkoff M for the VACS 5 Project Team. Neurocognitive and psychiatric disorders among HIV positive and negative veterans in care: Veterans Aging Cohort 5 Site Study. AIDS
15. Volberding PA. Levine AM. Dieterich D. Mildvan D. Mitsuyasu R. Saag M. Anemia in HIV Working Group* (JL
Guest, member). Anemia in HIV infection: clinical impact and evidence-based management strategies. Clin Infect Dis
16. Guest JL, Ruffin C, Tschampa JM, DeSilva KE, Rimland D. Differences in rates of diarrhea in patients with
human immunodeficiency virus receiving lopinavir/ritonavir or nelfinavir. Pharmacotherapy
17. Anderson KB, Guest JL, Rimland D. Hepatitis C coinfection increases mortality in HIV-infected patients in the
highly active antiretroviral therapy era: data from the HIV Atlanta VA Cohort Study. Clin Infect Dis
2004; 39: 1507-13.
18. Guest JL, Anderson KB, Rimland D. The hepatitis C and HIV coinfected patient, pre- and post-HAART
differences in survival in the HAVACS cohort. Contagion
19. Fisk TL, Lundberg BE, Guest JL, Ray S, Barrett TJ, Holland B, Stamey K, Angulo FJ, Farley MM. Invasive
infection with multidrug-resistant Salmonella enterica
serotype Typhimurium definitive type 104 among HIV-infected adults. Clin Infect Dis
20. Rimland D, Guest JL. Response to hepatitis A vaccine in HIV patients in the HAART era. AIDS
21. Rimland D, Guest JL, Hernandez I, del Rio C, Le NA, Brown WV. Increased apoCIII to triglyceride ratios in HIV
positive men on antiretroviral therapy. HIV Med
, 2005; 6:326-333.
22. Fultz SL, Goulet JL, Weisman S, Rimland D, Leaf D, Gibert C, Rodriguez-Barradas MC, Justice AC.
Differences between HIV and general medical providers in comfort with providing primary care. Clin Infect Dis
23. Rimland D, Guest JL, Hernandez I, del Rio C, Le NA, Brown WV. Antiretroviral therapy in HIV positive women
is associated with increased ApoC-III, triglycerides and total cholesterol. J Acquir Immune Defic Syndr
24. Osborn M, Guest JL, Rimland D. Hepatitis B and HIV coinfection: relationship of different serologic patterns on
survival and liver disease. HIV Med (in press)
Selected HAVACS abstracts:
1. Guest JL, Rimland D. Decreased incidence of CMV disease unrelated to use of HAART: data from
HAVACS (HIV Atlanta Veterans Affairs Cohort Study). Presented at the Society for Epidemiologic Research 32nd Annual Meeting, Baltimore, 1999.
2. Guest JL, Clark WS, Rimland D, Curran J, Liff J. Prognostic indicators beyond CD4+ thresholds to assess
risk of Pneumocystis carinii pneumonia and disseminated Mycobacterium avium complex in HIV+ patients: data from HAVACS (HIV Atlanta Veterans Affairs Cohort Study). Presented at the Society for Epidemiologic Research 32nd Annual Meeting, Baltimore, 1999.
3. Guest JL, Hamilton DT, Rimland D. The effect of the use of protease inhibitors on immunologic factors in
HIV+ patients: data from HAVACS (HIV Atlanta Veterans Affairs Cohort Study). Presented at the Society for Epidemiologic Research 33rd Annual Meeting, Seattle, 2000.
4. Gallagher L, Le Flore DB, Guest JL, DeSilva KE, Marston BJ, Rimland, D. The CARDS panel: a
collaborative approach to complicated antiretroviral decisions. Presented at the 12th Annual ANAC Conference, San Juan, PR, 2000.
5. Rimland D, Guest JL, Smith R. Incidence of herpes Zoster in HIV disease: no evidence for increase after
introduction of potent antiretroviral therapy. Presented at the 1st IAS Conference on HIV Pathogenesis and Treatment, Buenos Aires, Argentina, 2001.
6. DeSilva KE, Guest JL, Flaherty TD, Marston BJ, Rimland D. Tolerability of Efavirenz in patients with a
history of mental health disorder. Presented at the American College of Clinical Pharmacy 2001 Conference, Tampa, Florida, 2001. (Pharmacotherapy
7. Guest JL, Rimland D, Stolfus SA. Prognostic value of immunologic and virologic markers in late-stage HIV-1
disease: data from HAVACS (HIV Atlanta Veterans Affairs Cohort Study). Presented at the 9th Conference on Retroviruses and Opportunistic Infections, Seattle, Washington, 2002. (#268-T)
8. Rimland D, Guest JL, Anderson KB. The effect of hepatitis C coinfection on survival in the HIV Atlanta
Veterans Affairs Cohort Study (HAVACS) in the post HAART era. Presented at the 9th Conference on Retroviruses and Opportunistic Infections, Seattle, Washington, 2002. (#658-M)
9. Guest JL, DeSilva KE, Le Flore DB, Flaherty TD, Rimland D. Incidence of CNS effects in patients with a
history of mental health disorders and/or substance abuse starting an Efavirenz-containing regimen: data from HAVACS. Presented at the International AIDS 2002 Conference, Barcelona, Spain, 2002.
10. Guest JL, Ruffin C, DeSilva KE, Tschampa JM, Rimland D. Rates of treated diarrhea in patients on either a
Kaletra- or a Nelfinavir-containing regimen: data from HAVACS. Presented at the 40th Annual Meeting of Infectious Disease Society of America Conference, Chicago, 2002. (#476)
11. Mildvan D, Creasgh T, Leitz G and the Anemia Prevalence Study Group (J. Guest, member). Greater
prevalence of anemia in women and African Americans with HIV/AIDS in the HAART era: a study of about 10,000 patients. Presented at the 40th Annual Meeting of Infectious Disease Society of America Conference, Chicago, 2002. (#475)
12. Guest JL, Rimland D, Tschampa JM, DeSilva KE, Robinson M. Comparison of diarrhea in patients on
Nelfinavir-containing regimen followed by a lopinavir/ritonavir-containing regimen: data from HAVACS. Presented at HIV DART 2002: Frontiers in Drug Development for Antiretroviral Therapy, Naples, Florida, 2002. (#070)
13. Guest JL, Rimland D, Hernandez I, del Rio C, Le N-A, Brown WV. Elevated ApoC-III levels are associated
with hyperlipidemia in men and women on PI or NNRTI regimens. Presented at 2nd Annual Meeting for Lipodystrophy in HIV/AIDS Symposium and Retreat, Davis, California, 2003.
14. Hernandez I, del Rio C, Folch E, Lennox J, Le N-A, Rimland D, Guest JL, Brown WV. Lipid abnormalities
among Pi-treated women may be due to excess production of ApoC-III. Presented at the 10th Conference on Retroviruses and Opportunistic Infections, Boston, Massachusetts, 2003. (#751)
15. Guest JL, Rimland D, Hernandez I, del Rio C, Le N-A, Brown WV. Elevated ApoCIII levels are Associated
with Elevated Cholesterol and Triglycerides in HIV Positive Men on PI or NNRTI Regimens. Presented at the 10th Conference on Retroviruses and Opportunistic Infections, Boston, Massachusetts, 2003. (#749)
16. Rimland D, Guest JL. Mortality in the HIV Atlanta VA Cohort Study (HAVACS): A 22-Year Analysis.
Presented at the 11th Conference on Retroviruses and Opportunistic Infections, San Francisco, CA, 2004. (#873)
17. Rimland D, Guest JL. Response to hepatitis A vaccine in HIV patients in the HAART era. Presented at the
International AIDS 2004 Conference, Bangkok, Thailand, 2004. (#MoPeB 3299)
18. Guest JL, Ataher QS, Rimland D. Racial Differences in Response to EFV-Containing vs. LPV/r-Containing
Regimens. Presented at the 44th ICAAC, Washington DC, 2004. (#H-579)
19. Rimland D, Guest JL. Decreasing incidence of all pneumonias in the HAART era. Presented at the 12th
Conference on Retroviruses and Opportunistic Infections, Boston, MA, 2005. (#879)
20. Guest JL, Rimland D, Patterson B, DeSilva KE. Tenofovir induced nephrotoxicity in the first year of therapy:
Data from HAVACS (HIV Atlanta VA Cohort Study). Presented at the 13th Conference on Retroviruses and Opportunistic Infections, Denver CO, 2006. (#778)
21. Osborn M, Guest JL, Rimland D. Hepatitis B and HIV coinfection: relationship of different serologic patterns
on survival and liver disease. Presented at the 13th Conference on Retroviruses and Opportunistic Infections, Denver CO, 2006.
22. Guest, JL, Rimland D, Ataher Q. Characterization of lipid changes associated with lopinavir/ritonavir (LPV/r)
vs. efavirenz (EFV) with and without stavudine (d4T) in HIV-infected patients. Presented at the XVI International AIDS Conference, Toronto Canada, 2006. (#CDB0727)
23. Guest JL, Rimland D, Powell K, Patel A. Choice of first HAART regimen impacts survival: data from
HAVACS. Presented at the XVI International AIDS Conference, Toronto Canada, 2006. (#CDB0477)
24. Rimland D, Guest JL. Increasing incidence of prostate cancer in the Atlanta VA Cohort Study (HAVACS).
Presented at the 14th Conference on Retroviruses and Opportunistic Infections, Los Angeles CA, 2007. (#Q-105).
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THE BREATH OF LIFE A viewpoint from Susan Fairley 9th-11th April 2010 (with thanks to Mike Booth of Aura Soma for his numerological training) If you take the combined numerological value of the words BREATH OF LIFE it comes down to 8. The message is clear – “As above, so below”. Further deep and empowering messages and choices flow out of the preceding four levels of each word.