Journal of the International Association of Physicians in AIDS Care (JIAPAC) recent issues

HIV-Infected Thais Need Help to Adjust to a Normal Life in Society

Hultqvist, E., Martensson, T., Samnang, V., Andersson, R. — Wed, 16 Sep 2009 09:25:19 PDT

A Retrospective Analysis of AIDS-Associated Kaposi's Sarcoma in Patients With Undetectable HIV Viral Loads and CD4 Counts Greater Than 300 cells/mm3

Mani, D., Neil, N., Israel, R., Aboulafia, D. M. — Wed, 16 Sep 2009 09:25:19 PDT

Objective: To compare the clinical course of patients with AIDS-related Kaposi’s sarcoma (KS) with CD4 counts >300 cells/mm³ and undetectable HIV viral loads (VLs) to patients with AIDS-KS with lesser CD4 counts and detectable HIV VLs.

Methods: We retrospectively analyzed a cohort of 91 patients with AIDS-KS in a multispeciality clinic. We used ² and Student t tests to analyze intragroup differences; survival was determined by Kaplan-Meier analysis.

Results: Twenty (22%) of the 91 patients had newly diagnosed, persistent or progressive KS despite CD4 counts >300 cells/mm³ and undetectable HIV VLs. Age, gender, ethnicity, mode and duration of HIV acquisition, type of antiretroviral therapy (ART), and KS therapy did not differ significantly (P ≤ .005) between this group and the remaining 71 patients. Although tumor stage and response to KS therapy were similar, there was a significantly greater risk of death among the patients with CD4 counts <300 cells/mm³ and detectable HIV VLs (P = .048).

Conclusions: In the highly active antiretroviral (HAART) era, a substantial proportion of patients with KS had undetectable HIV VLs and CD4 counts greater than the level typically associated with opportunistic diseases. They required systemic therapy to control their KS but were significantly less likely to die and demonstrated a trend toward better 15-year survival than patients having KS with lesser CD4 counts and detectable HIV VLs.

Human Papillomavirus in Women With and Without HIV-1 Infection Attending an STI Clinic in Vitoria, Brazil

Wed, 16 Sep 2009 09:25:19 PDT

We conducted a cross-sectional study in Vitória, Brazil, to assess the prevalence of human papillomavirus (HPV) infection in HIV-positive and HIV-negative women attending a sexually transmitted infection (STI)/AIDS clinic. We also investigated the presence of HPV genotypes and assessed covariates for HIV infection. Enrolled patients received a gynecological evaluation, and cervical scrape samples were collected for cytological analysis and HPV-DNA polymerase chain reaction (PCR). A blood sample was obtained to determine HIV status. HPV infection and squamous intraepithelial lesions were studied in 284 women, 112 (39.4%) HIV-positive women and 172 (60.5%) HIV-negative women. HPV-DNA was detected in 133 (46.8%). HIV-infected women were almost twice as likely to be concurrently infected with HPV than HIV-negative women (OR = 1.87 95% CI: 1.16-3.03). The high proportion of HPV detected among women attending an STI/AIDS clinic, particularly among HIV-infected women, proves the importance of screening this high-risk group in the hope of earlier detection and treatment of cervical intraepithelial neoplasia (CIN).

When ''No'' Means ''Yes'': The Gender Implications of HIV Programming in a Zimbabwean University

Masvawure, T. B., Terry, P. E., Adlis, S., Mhloyi, M. — Wed, 16 Sep 2009 09:25:19 PDT

Objectives: This study assessed the nature and extent of sexual risk-taking behavior by students in a Zimbabwean university and identified some of the sociocultural factors that facilitate sexual risk taking by female and male students. The main outcome measures of the study were condom use, number of sexual partners, and attitudes toward gender equity and equality.

Methods: A cross-sectional design was used and a questionnaire was administered to 933 students. Information pertaining to students’ sexual practices, condom use practices, attitudes toward HIV testing, and their beliefs pertaining to women’s role in sexual decision making and a woman’s right to refuse sexual intercourse were among some of the variables assessed.

Results: The vast majority of the university students (83%) are sexually experienced; only a third used condoms at their last sexual encounter; the use or nonuse of condoms was significantly associated with age, sex, marital status, and attitudes toward gender issues. There were also significant differences in the sexual behavior and attitudes of female and male students.

Conclusion: Our study suggests that HIV prevention efforts targeted at university students need to incorporate a discussion of broader cultural beliefs, particularly those pertaining to gender role myths, if they are to be effective.

Comparison of 3-Drug Versus 4-Drug and PI Versus Non-PI Combinations as Initial HAART: Experience From 1998 to 2007

Jhaveri, M. A., Browning, S. R., Bush, H., Thornton, A., Greenberg, R. N. — Wed, 16 Sep 2009 09:25:19 PDT

Although established in controlled studies that there is no advantage to 4-drug highly active antiretroviral therapy (HAART) or regimens with or without protease inhibitors (PIs), we questioned this finding in a clinical setting (ie, no inclusion criteria). Ours is a single clinic retrospective study including all participants >18 years of age during their first year of HAART. A total of 190 participants were reviewed, with 168 (88%) attaining a viral load <400 copies/mL at the end of a year of HAART; 144 of 164 (88%) succeeded with 3 drugs and 24 of 26 (92%) with 4 drugs (P = .51). In all, 59 of 71 (83%) succeeded using a PI versus 109 of 119 (92%) without a PI (P = .08). Male gender and exposure time to HAART were significant variables for a successful outcome. Failures were due to side effects (50%), nonadherence (45%), and drug allergy (5%). Our results support current guidelines recommending 3-drug HAART.

Observational Study to Evaluate Clinical Outcomes After First-Line Efavirenz-or Lopinavir-Ritonavir-Based HAART in Treatment-Naive Patients

Wed, 16 Sep 2009 09:25:19 PDT

Purpose: To evaluate clinical, immunological, and virological outcomes after first-line highly active antiretroviral therapy (HAART) with a regimen including either efavirenz (EFV) or lopinavir/ritonavir (LPV/r) in treament-naive adult patients in routine clinical care.

Method: An ongoing prospective, observational follow-up study included all patients starting their first antiretroviral therapy (ART) with any of the studied regimens from July 1998 to July 2004. The follow-up period was finalized in September 2006, when all patients completed an observation of at least 96 weeks. Mortality rates, CD4 counts, viral suppression (HIV RNA below 50 copies/mL), and discontinuation of any component of the regimen were compared at 48 and 96 weeks.

Results: Despite the worst immunological status of the LPV/r group patients at baseline, this regimen was at least as effective as the one based on EFV not only in terms of treatment durability but also in terms of virological responses, nevertheless with an apparently quicker immune recovery. In general terms, both regimens present similar tolerability and safety outcomes except for the higher risk of increasing triglyceride (TG) levels in the LPV/r group. Low durability was observed in both regimens.

Conclusion: In a routine clinical care setting, initial HAART containing LPV/r seems to present an effectiveness, tolerability, and toxicity similar to the one containing EFV.

First HAART in HIV-Infected Patients With High Viral Load: Value of HIV RNA Levels at 12 Weeks to Predict Virologic Outcome

Wed, 16 Sep 2009 09:25:19 PDT

The aim of this study is to identify the role of incomplete suppression during the first months of highly active antiretroviral treatment (HAART) to predict virologic failure in patients with high levels of HIV replication. In a retrospective, longitudinal, and multicenter study, response to HAART was assessed in treatment-naive adults with HIV RNA >100 000 copies/mL, and factors predicting failure were analyzed through regression analyses. A total of 118 patients were included. Virologic failure occurred more often in patients with >500 copies/mL at week 12 (Cox regression: Exp (B) 3.22; P = .02). HIV RNA >500 copies/mL at week 12 predicted incomplete virologic response (odds ratio [OR] = 9.33; P = .002] but not viral rebound. Major antiretroviral resistant mutations were present in 11 of 14 patients. HIV RNA >500 copies/mL at week 12 of first HAART predicts incomplete virologic response in patients with high levels of replication at baseline. Most patients carried resistance mutations at the time of failure.

Adverse Drug Reactions to Nonnucleoside Reverse Transcriptase Inhibitor-Based Antiretroviral Regimen: A 24-Week Prospective Study

Jena, A., Sachdeva, R. K., Sharma, A., Wanchu, A. — Wed, 16 Sep 2009 09:25:19 PDT

Background: Few studies have addressed the issue of adverse drug reactions with non-protease inhibitor (PI)-based antiretroviral therapy (ART) in resource-constrained settings. We studied prospectively the incidence of adverse drug reactions with generic ART among our patients.

Methodology: A total of 100 HIV-infected individuals were recruited. Patients received nevirapine (NVP) or efavirenz (EFV) with lamivudine (3TC) and zidovudine (ZDV)/stavudine (d4T). They were followed for 6 months for evidence of adverse drug reactions.

Results: The mean CD4 count was 114.09 ± 60.07 cells/mm³ (range, 12-232 cells/mm³). Transient gastrointestinal symptoms were most frequent. Fourteen individuals (12 receiving ZDV/d4T, 3TC, NVP and 2 receiving ZDV/d4T, 3TC, EFV) developed skin rash. Among patients receiving NVP, 25.7% developed grade 1 hepatotoxicity. Three patients had numbness in both lower limbs. Among those individuals who received EFV, 32.3% individuals had central nervous system (CNS) symptoms in the form of insomnia, vivid dreams, dizziness, and drowsiness.

Conclusion: As the developing world increasingly uses generic ART, the clinician must be constantly vigilant for treatment-related adverse events.

Primary HIV-1 Drug Resistance and Polymorphic Patterns Among Injecting Drug Users (IDUs) in Chennai, Southern India

Iqbal, H. S., Solomon, S. S., Madhavan, V., Solomon, S., Balakrishnan, P. — Wed, 16 Sep 2009 09:25:19 PDT

Background and Objective: India has 1.1 million injecting drug users (IDUs) with an HIV prevalence rate as high as 64%. Drug resistance screening before therapy is beneficial to the individual. Here, we have studied primary drug resistance among IDUs in Chennai.

Methods: Specimens (n = 55) collected between March 2005 and April 2006 were subjected to genotyping assay. The mutations for the drug resistance were interpreted using the Stanford HIV Drug Resistance Database.

Results: M41LM (1.8%), K65KN (1.8%), and G73GS (2.7%) were found to be associated with low-level resistance to zidovudine (ZDV), stavudine (d4T), abacavir (ABC), didanosine (ddI), emtricitabine (FTC), tenofovir (TDF), and saquinavir (SQV) in each specimen. The rate of polymorphisms is significantly different from universally established subtype ‘‘C’’-specific polymorphisms (P < .0001).

Conclusion: The presence of drug resistance mutations, though minimal, is alarming as it could spread easily between IDUs and from them to their sexual partners. The genetic variation is of importance in vaccine design.

Immune Reconstitution Visceral Leishmaniasis Presented as Hemophagocytic Syndrome in a Patient With AIDS From a Nonendemic Area: A Case Report

Patel, K. K., Patel, A. K., Sarda, P., Shah, B. A., Ranjan, R. — Mon, 31 Aug 2009 15:51:52 PDT

Visceral Leishmaniasis (VL) is endemic in the Ganges and Brahmaputra plains of India. Leishmaniasis/HIV coinfection is on the rise in India and may pose a real diagnostic and therapeutic challenge. HIV-related immunosuppression increases the risk of reactivating leishmaniasis by 100 to 1000 times and it also increases the risk of drug resistant leishmaniasis. Immune reconstitution VL is not very well reported in literature. Hemophagocytosis is known to occur with various infectious agents like viruses, bacteria, and parasites, but is rare to occur with leishmaniasis. Here the authors describe a case of VL presenting as immune reconstitution disease and hemophagocytosis in an HIV infected patient coming from a nonendemic area.

Risk-Taking Behaviors Among Vertically HIV-Infected Adolescents in Northern Thailand

Lee, B., Oberdorfer, P. — Mon, 31 Aug 2009 15:51:52 PDT

Purpose. To examine risk-taking behaviors and HIV self-disclosure among vertically HIV-infected adolescents in northern Thailand. Methods. A quantitative survey was conducted from 2007 to 2008 at 2 pediatric HIV clinics in northern Thailand among vertically HIV-infected adolescents aged ≥13 years, with disclosed HIV status. The survey assessed sociodemographics, substance use, sexual behavior, peer behaviors, knowledge, and attitudes regarding HIV disclosure. Results. Fifty-four adolescents (median age 14.6 years) participated; 18.5% reported previous alcohol use but none reported drug use; 35.2% reported presexual activity, and 3.7% reported sexual activity. Nearly all (96.3%) knew that HIV could be transmitted sexually, but knowledge regarding other sexually transmitted infections (STIs) was poor. Nearly half (48.1%) had never disclosed their status to anyone. Conclusions. Rates of substance use and sexual activity were low in this population. STI knowledge was poor and diagnosis self-disclosure was infrequent. Improved sexual education and self-disclosure skills are needed among vertically HIV-infected adolescents in Thailand.

Cold Agglutinins in HIV-Seropositive Participants and Diagnosis of Respiratory Disease Due to Mycoplasma pneumoniae

Mon, 31 Aug 2009 15:51:52 PDT

Objectives. Cold agglutinin (CA) titers are one among the first pathological indicators for diagnosing Mycoplasma pneumoniae disease. We prospectively studied the prevalence of CAs in 300 HIV-positive and 75 HIV-negative individuals with respiratory disease in Chennai, India. Methods. The cold agglutination test was used and retrospectively compared with the results of a particle agglutination test. Results. While CAs were positive in 51 HIV cases, particle agglutination test detected anti-M pneumoniae antibodies from 43 cases with HIV disease (P = .001). The seroprevalence of CAs was 2.6% (n = 2) among HIV-negative participants. The mean CD4 count in CApositive and -negative HIV cases was 107.4 + 121.2 and 259.2 + 247.2 cells/µL (P = .001), respectively. Conclusion. Our report suggests a basis for the existence of CAs in HIV-positive cases. Definitive diagnosis may be done only when CA detection is used in conjunction with a specific test.

Strongyloides stercoralis Hyperinfection in a Patient With AIDS

Bava, A. J., Troncoso, A. R. — Mon, 31 Aug 2009 15:51:52 PDT

Strongyloides stercoralis is a prevalent cause of severe infection and death in many areas of the world where fecal contamination of soil or water is common. The nematode is endemic in tropical and subtropical regions of the world, including northeastern Argentina, where infection rates may exceed 30% of the population. Strongyloides infections are often light and associated with few or no signs and symptoms, particularly during initial migration through the body. However, certain persons are at risk of severe, clinically significant disease developing. The manifestations of hyperinfection syndrome are divided, based on the system of origin, into intestinal and extraintestinal disease mainly involving the respiratory tract. Unfortunately, S stercoralis hyperinfection is seldom diagnosed until late in the course of the disease, which contributes to a high death rate. In patients with the hyperinfection syndrome and massive Strongyloides infection, adult respiratory distress syndrome with pulmonary insufficiency that requires intubation and mechanical ventilation may also develop. We report a case of S stercoralis hyperinfection in an HIV-infected patient, which resulted in death.

Radiation Therapy for HIV-Associated Diffuse Large Cell Non-Hodgkin Lymphoma

Rothschild, S., Dolder, M., Seifert, B., Lutolf, U. M., Ciernik, I. F. — Mon, 31 Aug 2009 15:51:52 PDT

Purpose. To report the clinical experience with external beam radiotherapy (RT) for AIDS-related lymphoma (ARL) with or without the involvement of the central nervous system (CNS) in HIV-infected patients. Patients and Methods. Clinical outcome of 24 HIV-seropositive patients with ARL treated with RT from 1995 to 2004 was reviewed, testing factors associated with outcome. Results. After 1 and 5 years, the overall survival was 65% and 35%, respectively. The mean RT dose was 31 Gy after normalization to fractions of daily 2 Gy (range, 7.8-47.2 Gy). Radiotherapy dose was associated with survival in univariate (P = .04) and multivariate analysis (P = .01). Other factors in univariate analysis associated with outcome were viral load (VL), highly active antiretroviral therapy (HAART), ARL stage, and CNS involvement. Patients with CNS involvement achieved complete response in 46% and improved clinical performance was seen in 73%. Conclusions. After chemotherapy, RT in combination with HAART is highly active, and RT should be encouraged especially after suboptimal responses to induction treatment.

Clinicians' Knowledge of 2007 Food and Drug Administration Recommendation to Discontinue Nelfinavir Use During Pregnancy

Fogler, J., Weber, S., Mahoney, M. R., Goldschmidt, R. H. — Mon, 31 Aug 2009 15:51:52 PDT

In 2007, the US Food and Drug Administration (FDA) and Pfizer Inc recommended immediate discontinuation of nelfinavir (NFV) during pregnancy due to contamination with a potential teratogen. A few weeks after the announcement, we surveyed antenatal HIV care providers to determine how widely the warning was disseminated. Overall, 69 of 121 (57.0%) providers knew to discontinue NFV. Callers with more than 50 HIV-infected patients were 2.54 times as likely to be aware as callers with 1-3 HIV-infected patients (P < .01). Only 12 (33.3%) obstetricians were aware, compared to 21 (80.8%) infectious diseases specialists (P < .001). The FDA/Pfizer Inc recommendation to avoid nelfinavir mesylate (NFV) in pregnancy appears to have successfully reached HIV experts. However, not all pregnant women have access to experts and may receive most of their care from providers without extensive HIV experience. More effective dissemination of critical HIV-related information to all antenatal care providers, including general obstetricians, family physicians, and midwives, may be needed.

Obstacles and Proposed Solutions to Effective Antiretroviral Therapy in Resource-Limited Settings

Bartlett, J. A., Hornberger, J., Shewade, A., Bhor, M., Rajagopalan, R. — Mon, 31 Aug 2009 15:51:52 PDT

More than 3 million people were receiving antiretroviral therapy (ART) at the end of 2007, but this number represents only 31% of people clinically eligible for ART in resource-limited settings. The primary objective of this study is to summarize the key obstacles that impede the goal of universal access prevention, care, and treatment. We performed a systematic literature search to review studies that reported barriers to diagnosis and access to treatment of HIV/AIDS in resource-limited countries. Persons living with HIV/ AIDS commonly face economic, sociocultural, and behavioral obstacles to access treatment and care for HIV. A variety of programs to overcome these barriers have been implemented, including efforts to destigmatize HIV/AIDS, enhance treatment literacy, provide income-generation skills, decentralize HIV services, promote gender equality, and adopt a multisectoral approach to optimize limited resources. An understanding of these obstacles and suggested methods to overcome them must be addressed by global policy makers before universal ART access can be achieved.

Cofactors for Low Serum Albumin Levels Among HIV-Infected Individuals in Southern India

Fri, 29 May 2009 14:58:14 PDT

Background and aims. Malnutrition and low serum albumin among human immunodeficiency virus (HIV)-infected individuals are cofactors for HIV disease progression. The present study aimed to identify the proportion of HIV-infected individuals with low serum albumin and the possible cofactors among highly active antiretroviral therapy (HAART) experienced and HAART naïve individuals. Methods. A total of 835 HIV-infected individuals (HAART-experienced, HAART-naïve) were included in the study. Results. Of the 835 individuals, 44.6% had normal (4.2-5.2 g/dL) and 55.4% had abnormal (<4.2 g/dL) albumin levels. The abnormal group had significantly lower body mass index (BMI) compared with the normal group (P = .02). Among those with abnormal albumin, 388 (84%) were HAART experienced compared with 239 (64%) with normal albumin (P < .001). Among the abnormal group, 259 (55.9%) had CD4 count <200 cells/mL as compared with 124 (33.3%) in the normal group (P < .001). Conclusions. CD4 count and lower were the major cofactors for low serum albumin among HIV-infected individuals. Therefore, serum albumin would be a useful biochemical test for HIV disease in resource-limited settings.

Daily Trimethoprim-Sulfamethoxazole Prophylaxis Rapidly Induces Corresponding Resistance Among Intestinal Escherichia coli of HIV-Infected Adults in Kenya

Fri, 29 May 2009 14:58:14 PDT

Background. Trimethoprim-sulfamethoxazole (TMP-SMZ) has been recommended by World Health Organization (WHO) as daily prophylaxis for Africans with AIDS to prevent opportunistic infections. Daily TMP-SMZ may reduce its susceptibility to commensal intestinal Escherichia coli (E coli), increasing the burden of TMP-SMZ-resistant pathogens. Methods. Participants received either daily TMP-SMZ (CD4 <350 cells/mm³) or daily multivitamins (MVIs; CD4 ≥350 cells/mm³) for 6 months. Stool was collected at baseline, 2 weeks, 2 months, and 6 months. A random E coli was tested for susceptibility. Results. Baseline prevalence of TMP-SMZ resistance ranged from 71% to 81% and was not different across CD4 strata. At 2 weeks, prevalence of TMP-SMZ-resistant E coli increased significantly from 78% to 98% (P < .001) among persons taking daily TMP-SMZ and did not change among persons taking MVIs. Conclusions. Daily prophylaxis with TMP-SMZ induced in vivo resistance to the drug after 2 weeks. Empiric therapy for diarrhea with agents other than TMP-SMZ should be considered for HIV-infected persons receiving daily TMP-SMZ prophylaxis.

Trends in HIV/TB Coinfection in Trinidad and Tobago for the Period 1998-2007

Fri, 29 May 2009 14:58:14 PDT

Objectives. The aim of this study was to extend the description of the epidemiologic pattern of human immunodeficiency virus (HIV)/tuberculosis (TB) coinfection from 1998 to 2007 in a high HIV/AIDS prevalence country. Design and Methods. This study utilized registry data to determine yearly TB incidence and HIV coinfection. Mortality rates for coinfected patients were calculated and compared with patients receiving highly active antiretroviral therapy (HAART). Results. From a TB population of 2010 registered patients, data was collected on the 466 patients with HIV/TB coinfection. The coinfection rate was found to be 23.6% for the study period. Patients on HAART were twice as likely to survive. Discussion and Conclusions. The incidence of TB and HIV/TB coinfection rates continues to be major challenges in the developing world. Demographic, socioeconomic trends as well as risk factors remain unchanged. Increased HIV screening and HAART coverage offers hope for the future.

Community-Associated Methicillin-Resistant Staphylococcus aureus Skin and Soft-Tissue Infection in HIV-Infected Patients

Trinh, T. T., Short, W. R., Mermel, L. A. — Fri, 29 May 2009 14:58:14 PDT

Background. Community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) has emerged as the most common cause of skin and soft tissue infections (SSTIs). Methods. Retrospective chart review of 43 adult HIV-infected patients with CA-MRSA SSTI was conducted. Results. Antibiotic susceptibility was as follows: vancomycin (100%), rifampin (100%), gentamicin (97.7%), tetracycline (96.5%), trimethoprim-sulfamethoxazole (95.2%), clindamycin (89.5%), levofloxacin (66.7%), and erythromycin (6.9%). At SSTI presentation, 58.5% of patients had CD4 counts greater than 200 cells/uL, 82.9% had a viral load (VL) below 100 000 log copies/mL, 6 of whom had undetectable VL. All 43 patients received empiric antibiotic therapy. Additionally, 34 patients underwent incision and drainage (I&D). For the 37 patients with follow-up data available at 4 weeks, 30 of the infections were resolved/resolving and 7 had no improvement or worsened. Conclusion. A majority of our patients with CA-MRSA SSTI did not have immunological/virological markers consistent with severe HIV/AIDS disease at time of presentation.

Dried Blood Spots Versus Plasma for the Quantification of HIV-1 RNA Using the Manual (PCR-ELISA) Amplicor Monitor HIV-1 Version 1.5 Assay in Yaounde, Cameroon

Ikomey, G.M., Atashili, J., Okomo-Assoumou, M.C., Mesembe, M., Ndumbe, P.M. — Fri, 29 May 2009 14:58:14 PDT

Objectives: Considering the recent accrued need for viral load quantification in resource-limited settings, this study evaluated the use of dried blood spots (DBS) compared to plasma as a means of sample collection and storage for HIV-1 RNA quantification using a non-automated assay. Methods: Venous blood was collected from 60 consenting HIV-1-positive patients, plasma separated within 4 hours, and stored at -20°C. Venous blood, 50 µL, was blotted on 4 designated areas of Whatman filter paper and air-dried at room temperature for 2 hours. Results: There was a strong statistically significant correlation between HIV-1 RNA viral load using plasma and DBS (r = .955, P < .001). On average plasma viral loads were only slightly higher than DBS viral loads (mean difference: 0.06 log₁₀ copies/mL). Conclusion: Even when using an entirely manual HIV-quantification assay, DBS may provide a reliable, cost-effective method for sample collection and storage for HIV-1 RNA quantification in resource-limited settings.

Enteric Bacterial Pathogens in HIV-Infected Children With Acute Diarrhea in Mulago Referral and Teaching Hospital, Kampala, Uganda

Musiime, V., Kalyesubula, I., Kaddu-Mulindwa, D., Byarugaba, J. — Fri, 29 May 2009 14:58:14 PDT

Objective. HIV-infected children develop severe bacterial infections. We set out to determine the enteric bacterial pathogens in HIV-infected children and HIV-negative controls with acute diarrhea and their antimicrobial sensitivities. Methods. Children below 5 years of age with acute diarrhea were screened for HIV and their stools were analyzed by culture and use of antisera and the sensitivities of the pathogens were determined using the Kirby Bauer disc diffusion method. Results. Of the 190 children, 47 were HIV positive. The prevalence rates of the pathogens in HIV-infected and -uninfected children were 19% (9/47) and 27% (38/143), respectively; odds ratio = 0.64 (95% confidence interval 0.20-1.97), P value .396. The pathogens in HIV-infected and -uninfected children were Escherichia coli, Salmonella, and Shigella species. Most isolates were resistant to cotrimoxazole. Conclusions. Escherichia coli, Salmonella, and Shigella species significantly cause acute diarrhea in HIV-infected and -uninfected children and they are highly resistant to cotrimoxazole.

Seven-Year Follow-Up on Lopinavir/ Ritonavir Monotherapy

Pierone, G., Mieras, J., Martin, A., Urban, T. — Fri, 29 May 2009 14:58:14 PDT

Previous studies of lopinavir/ritonavir (LPV/r) monotherapy have shown that over 70% of patients achieved HIV RNA levels <500 copies/mL over a follow-up period of 48 to 96 weeks, but the long-term durability is undetermined. Herein, the authors report 2 patients that started LPV/r monotherapy after virologic failure on an NNRTIbased regimen and have been successfully treated for greater than 7 years. Both patients demonstrated long-term control of viral replication over the course of treatment, although the first patient had 3 viral load blips and the second had 1 blip under 400 copies/mL. Both patients had increases in CD4+ lymphocyte counts. The first patient from 96 cells/µL to 378 cells/µL and the second patient from 71 cells/µL to 411 cells/µL. To the authors knowledge, these 2 cases represent the longest experience with LPV/r monotherapy and provide some measure of reassurance about the durability of LPV/r for control of HIV replication.

Prevalence of Antiretroviral Drug Resistance in Antiretroviral-Naive Individuals

James, C. W., Moffett, L. E., Szabo, S. — Fri, 29 May 2009 14:58:14 PDT

Transmitted antiretroviral drug resistance has been an ongoing consideration even in patients who are treatment naive. The authors retrospectively selected all eligible patients from a US-based urban HIV clinic who had a genotypic resistance assay performed prior to the initiation of antiretroviral therapy. Clinically significant resistance was detected in 8% of assays, and was comparable when stratified by duration of time from diagnosis to genotypic resistance assay.

HIV Testing and Treatment Among At-Risk Drinking Injection Drug Users

Arasteh, K., Des Jarlais, D. C. — Fri, 29 May 2009 14:58:14 PDT

Objective. To test the hypothesis that at-risk drinking is associated with a smaller probability of prior HIV testing and access to antiretroviral treatment (ART) among injection drug users (IDUs) entering treatment for drug abuse. Methods. HIV infected IDUs (N = 643) entering detoxification or methadone maintenance treatment in New York City between 1997 and 2002 comprised the participants. Multivariate logistic regression was used to assess whether receiving ART was associated with at-risk drinking. Results. A significantly smaller proportion of at-risk drinkers, compared to nondrinkers and moderate drinkers, reported receiving ART. Multivariate logistic regression analyses showed a significant interaction between alcohol and cocaine use in relation to reported ART. At-risk drinkers who used crack cocaine were less likely to receive ART compared to nondrinkers who did not use crack cocaine. Conclusion. HIV treatment programs should address at-risk drinking through screening for alcohol use and educating staff to improve the lower rate of ART reported by at-risk drinking IDUs.

Known to Be Positive But Not in Care: A Pilot Study From Thailand

Rithpho, P., Grimes, D. E., Grimes, R. M., Senaratana, W. — Fri, 29 May 2009 14:58:14 PDT

This study was designed to describe persons with HIV/ AIDS (PWHAs) in Thailand who have not disclosed their HIV status to the government HIV clinics to receive medical care. Objectives were to (1) demonstrate a way to access these persons, and (2) describe their characteristics, HIV status, reasons for nondisclosure, and problems related to their self-care. Two nongovernmental organizations (NGOs) serving the nonmedical needs of PWHAs were used. In all, 22 PWHAs participated. Approximately 80% have known their HIV status for more than 1 year and 30% for more than 5 years. Almost 60% currently used recreational drugs. Reasons for not disclosing their HIV status included that they were still healthy (81.8%) and worried about stigma (77.3%). Two thirds will disclose when a serious problem occurs. This study demonstrates that this population can be accessed and studied through NGOs and that this population differs slightly from PWHAs in Thailand studied at initiation of medical care.

Awareness and Attitude of Health Workers at a Nigerian HIV Treatment Clinic Toward HIV/AIDS and HAART Adherence

Olowookere, S. A., Fatiregun, A. A., Osagbemi, K. G. — Fri, 29 May 2009 14:58:14 PDT

Objective. To assess the awareness and attitude of antiretroviral clinic workers to HIV/AIDS and highly active antiretroviral therapy (HAART). Methods. A descriptive cross-sectional study design using a self-administered questionnaire was used. Results. Of the 43 staff, 39 (92.5%) completed the questionnaire. Their mean age was 35.1 + 7.6 years. There were 19 (48.7%) males and 20 (51.7%) females. The majority (87.2%) had tertiary education. More than three fifths (61.5%) were married. There were 20 (51.3%) professional staff and 19 (48.7%) support staff. Only 28.2% of staff members had ever received on-the-job training in HIV/AIDS care. None of the adherence counselors had ever received any training in HIV/AIDS care and HAART adherence counseling. Despite this lack of training, this majority of the clinic staff had good knowledge about and a positive attitude to HIV/AIDS and HAART adherence. Conclusion. Adherence counselors and support staff required on-the-job training for optimum job performance.

Analysis of a Switch From Enfuvirtide to Raltegravir in Patients With Undetectable Viral Load: Efficacy and Quality of Life at 24 Weeks

Wed, 15 Apr 2009 16:53:43 PDT

Raltegravir With Unboosted Atazanavir 300 mg Twice Daily in Antiretroviral Treatment-Experienced Participants

Gupta, S., Lataillade, M., Farber, S., Kozal, M. J. — Wed, 15 Apr 2009 16:53:44 PDT

Raltegravir (RAL) is an HIV integrase inhibitor characterized by potent antiretroviral activity, few adverse effects, and lack of cross-resistance to other antiretroviral (ARV) agents. RAL is emerging as a component of effective alternative ARV therapy for those who experience therapeutic failure or intolerance to reverse transcriptase inhibitors (NRTI and NNRTI) and ritonavir (RTV)-boosted protease inhibitor (PI) containing regimens. The combination of RAL with atazanavir (ATV) without a concomitant NRTI-based backbone or the inclusion of RTV may provide an alternative strategy for those unable to tolerate these latter ARV agents. In this report the authors present a case series of treatment-experienced patients managed with RAL + ATV given without a boosting dose of RTV. All patients tolerated this regimen over a course of 25 to 82 weeks, and had good virologic and immunologic outcome with a decrease in HIV RNA levels to <50 copies/mL and a mean CD4 count increase of 234 cells/mm³.

Relationship of Psychological Distress and Unprotected Sex Among Individuals With HIV Seeking Mental Health Care

Shacham, E., Basta, T. B., Reece, M. — Wed, 15 Apr 2009 16:53:44 PDT

This study examined the prevalence of sexual behavior and its relationship with psychological distress among individuals with HIV who were seeking mental health care. Upon self-enrollment in HIV-related mental health care, 845 participants completed self-assessments of demographics, psychological distress, and sexual behaviors. Participants were categorized by sexual risk as determined by their reported unprotected sexual activity within the previous 30 days: receptive anal or vaginal sex (high-risk), insertive anal or vaginal sex (moderate-risk), oral sex (low-risk), and no sex (no-risk). The majority of the sample was classified as no-risk, 11% low-risk, 5% moderate-risk, and 17% were high-risk. Levels of psychological distress did not differ across risk levels. Overall psychological distress levels were elevated, 19% of the sample expressed severe distress. Use of illicit drugs, alcohol, and no-AIDS diagnosis predicted high-risk sexual behaviors. A substantial proportion of the sample reported engaging in high-risk sexual behaviors, which signifies the need to further incorporate sex-related prevention efforts among HIV-infected populations.

High Seroprevalence But Low Incidence of HCV Infection in a Cohort of Patients With Sexually Transmitted HIV in Andalusia, Spain

Wed, 15 Apr 2009 16:53:44 PDT

Purpose. To analyze the prevalence and the incidence of hepatitis C virus (HCV) seropositivity in sexually transmitted human immunodeficiency virus (HIV) patients. Methods. Observational study of 1468 sexually transmitted HIV-infected patients from 7 hospitals (Southern Spain). Characteristics of HCV cases, and incidence of HCV seroconversion was assessed. Results. Seroprevalence of HCV was 16.1%, higher among heterosexual than homosexual patients, and similar between heterosexual men and women. Seroincidence was 0.16 cases per 100 patient-years, similar between homosexual and heterosexual patients. HCV patients had a mean CD4 of 523 cells/µL, 82.0% were on highly active antiretroviral therapy (HAART), and 72.0% had undetectable HIV viral load. Serum HCV-RNA was positive in 79.0% cases, and only 16.0% had ever received HCV treatment. Conclusions. HCV seroprevalence among sexually transmitted HIV-infected patients is more frequent than in the general population; however, incidence of HCV infection is currently low. Patients with sexually transmitted HIV coinfected with HCV have their HIV infection well controlled, but HCV infection was treated in few cases.

Prevalence of HIV-1 Subtypes in Brazilian Children With Perinatally Acquired Infection

Wed, 15 Apr 2009 16:53:44 PDT

HIV-1 infection has increased among women in recent years. The HIV-1 env gene (structural gene) has the greatest variation in all the HIV gene regions. In this study, 58 samples from infants infected with HIV-1 via perinatal transmission were analyzed. All the 58 samples were submitted to Nested-polymerase chain reaction of the env gene region for posterior viral genotyping using EN 70 and EN 85 (first polymerase chain reaction) and EN 80 and EN 95 (second polymerase chain reaction) primers, with the product of the 682 base pair amplification. After Nested-polymerase chain reaction for genotyping, purification of the product, and direct sequencing in a MegaBace 1000 automatic sequencer, 56 genotypes were found in the 58 HIV-1-positive children of the study, where 47 (83.93%) were HIV-1 subtype B infected and 9 (16.07%) were HIV-1 subtype F1 infected. The results demonstrate the predominance of subtype B followed by subtype F in Southeast Brazil.

Iatrogenic Cushing's Syndrome in HIV-Infected Patients Receiving Ritonavir and Inhaled Fluticasone: Description of 4 New Cases and Review of the Literature

Valin, N., De Castro, N., Garrait, V., Bergeron, A., Bouche, C., Molina, J. M. — Wed, 15 Apr 2009 16:53:44 PDT

Protease inhibitors boosted with ritonavir can lead to drug—drug interactions, particularly with inhaled corticosteroids such as fluticasone, because of the potent inhibition of cytochrome P450-3A4 activity. We report 4 cases of iatrogenic Cushing's syndrome after concomitant administration of inhaled fluticasone and antiretroviral therapy including a protease inhibitor boosted with ritonavir. Although typical manifestations were present, diagnosis of Cushing's syndrome was delayed because the patients were suspected to have antiretroviral therapy-associated lipodystrophy, which shares common clinical features with Cushing's syndrome. Biochemical tests confirmed iatrogenic Cushing's syndrome and clinical symptoms resolved after stopping ritonavir or fluticasone. The differences between the clinical symptoms of Cushing's syndrome and lipodystrophy are discussed as well as their frequency in the cases reported in the literature. The recommendation that concomitant administration of inhaled or intranasal fluticasone and ritonavir be prohibited must be implemented among practitioners who treat HIV-infected patients, and if long-term inhaled steroids are required, other drugs should be preferred.

Immune Reconstitution Inflammatory Syndrome in a Resource-Poor Setting

Wed, 15 Apr 2009 16:53:44 PDT

The immune reconstitution inflammatory syndrome (IRIS) associated with highly active antiretroviral therapy (HAART) was studied in rural Ethiopian HIV-infected patients. Review of 1002 charts in an outpatient clinic was conducted. The median CD4 count was 89 cells/mm³. Ninety-eight patients were hospitalized after initiation of HAART, of whom 74 were hospitalized for manifestations of IRIS (ie, 7% of patients on HAART). Of the 74 patients hospitalized with IRIS, 27 patients had tuberculosis; 12 patients, cryptococcal meningitis; 7 patients, toxoplasmosis; 6 patients, pneumonia and/or effusion; and 5 patients, Pneumocystis jiroveci pneumonia (PCP). Ten adult patients were admitted with gastroenteritis, heretofore not recognized as a manifestation of IRIS. Eighty-one percent of IRIS patients were hospitalized within 3 months of beginning HAART and 99% by 6 months. Of those hospitalized with IRIS, 4 patients (5%) died while in the hospital (3 with cryptococcal meningitis). Thirty-seven or 50% of those hospitalized with IRIS were lost to medical follow up, thus the mortality rate is likely a gross underestimate of the severity of IRIS. In resource-poor settings where the primary goal is to initiate HAART, IRIS may go unrecognized and have fatal consequences.

Hematologic Changes Associated With Zidovudine Following Single-Drug Substitution From Stavudine in a Home-Based AIDS Care Program in Rural Uganda

Wed, 15 Apr 2009 16:53:44 PDT

Background. The authors evaluated hematologic changes associated with zidovudine (ZDV) following single-drug substitution from stavudine (D4T) in HIV-infected persons in Uganda. Methods. From May 2003 through February 2007, the authors evaluated incidence rates (IR) of hematologic abnormalities from quarterly blood draws among adults prescribed highly active antiretroviral therapy (HAART) before and after single-drug substitution of D4T to ZDV. Results. A total of 1089 adults received D4T-containing HAART (median observation time, 35.9 months), and 290 (27%) had ZDV substituted for D4T. While taking D4T, IR for anemia was 0.35/100 person-months (PMs), leukopenia was 0.29/100 PM, and thrombocytopenia was 0.32/100 PM. While taking ZDV, IR for anemia was 0.44/100 PM, leukopenia was 1.05/100 PM, and thrombocytopenia was 0.30/100 PM. Conclusions. Patients had a higher incidence of anemia and leukopenia after substitution from D4T to ZDV, but hematologic toxicity was not a major complication in this population. Patients on ZDV-containing HAART regimens are still at risk for anemia and need close monitoring.

Adherence and Treatment Response Among HIV-1-Infected Adults Receiving Antiretroviral Therapy in a Rural Government Hospital in Southwestern Uganda

Wed, 15 Apr 2009 16:53:44 PDT

Background. Large-scale, government-based antiretroviral therapy (ART) programs in rural areas of resource-poor countries remain largely unevaluated. Methods. We conducted a retrospective review of all patients receiving ART (n = 399) to assess survival and retention in care and a prospective evaluation of patients on ART for at least 6 months (n = 175). We used 3-day self-report to measure adherence. Results. The probability (95% confidence interval [CI]) of surviving and remaining in care was 0.76 (0.72, 0.81) at 1 year. Men and patients with advanced disease were more likely to die or be lost to follow-up. At baseline, 149 (85%) reported 100% adherence. Nonadherence was associated with lack of suppression of viral replication (odds ratio [OR] = 4.5; 95% CI: 1.8, 11.5). Missing a scheduled clinic visit and lack of disclosure of HIV status were associated with nonadherence. Conclusion. Viral suppression was high, but counseling to include HIV disclosure to family and keeping scheduled clinic appointments may improve long-term adherence and treatment outcomes.