The changing clinical epidemiology of AIDS in the highly active antiretroviral therapy era

Patterns of emotional and behavioural challenges in children living with HIV: results from a hyperendemic South African setting

This study examined the patterns of emotional and behavioural problems in children from an HIV hyperendemic sub-Saharan Africa setting. A cross-sectional questionnaire survey was administered to 198 parents/caregivers of children living with HIV aged 2-12 years, attending a paediatric HIV out-patient service at a public sector hospital in KwaZulu-Natal Province, South Africa. The parent version of the Strengths and Difficulties Questionnaire (SDQ) which consists of five sub-scales (i.e. emotional difficulties, conduct problems, hyperactivity/inattention symptoms, peer problems and prosocial behaviours) were used to capture data on emotional and behavioural problems in children. The results indicated that over half of sampled children (n = 115, 58.1%) had abnormal levels of problems in at least one sub-scale, with adjusted regression indicating that academic difficulties and delayed milestones were significantly associated (i.e. greater total SDQ score as a continuous measure). Lower parental/caregiver educational attainment (i.e. not having tertiary education) was the only parent/caregiver characteristic associated with greater emotional and behavioural problems. Given the high prevalence of emotional and behavioural problems and its link to academic difficulties and delayed milestones, the need for screening and developmental support for children living with HIV may be warranted.

Multivariate multilevel modeling of quality of life dynamics of HIV infected patients

BACKGROUND

Longitudinal quality of life (QoL) is an important outcome in many chronic illness studies aiming to evaluate the efficiency of care both at the patient and health system level. Although many QoL studies involve multiple correlated hierarchical outcome measures, very few of them use multivariate modeling. In this work, we modeled the long-term dynamics of QoL scores accounting for the correlation between the QoL scores in a multilevel multivariate framework and to compare the effects of covariates across the outcomes.

METHODS

The data is from an ongoing prospective cohort study conducted amongst adult women who were HIV-infected and on the treatment in Kwazulu-Natal, South Africa. Independent and related QoL outcome multivariate multilevel models were presented and compared.

RESULTS

The analysis showed that related outcome multivariate multilevel models fit better for our data used. Our analyses also revealed that higher educational levels, middle age, stable sex partners and higher weights had a significant effect on better improvements in the rate of change of QoL scores of HIV infected patients. Similarly, patients without TB co-infection, without thrombocytopenia, with lower viral load, with higher CD4 cell count levels, with higher electrolytes component score, with higher red blood cell (RBC) component score and with lower liver abnormality component score, were associated with significantly improved the rate of change of QoL, amongst HIV infected patients.

CONCLUSION

It is hoped that the article will help applied researchers to familiarize themselves with the models and including interpretation of results. Furthermore, three issues are highlighted: model building of multivariate multilevel outcomes, how this model can be used to assess multivariate assumptions, involving fixed effects (for example, to examine the size of the covariate effect varying across QoL domain scores) and random effects (for example, to examine the rate of change in one response variable associated to changes in the other).

Health-Related Quality of Life Among People Living with Human Immunodeficiency Virus on Highly Active Antiretroviral Therapy in Ethiopia: PROQOL-HIV Based Survey

Background

As infection with the Human Immunodeficiency Virus (HIV) has evolved into a chronic disease, perceived health-related quality of life (HRQoL) is becoming a prominent and important patient-reported outcome measure in HIV care. This study aimed to assess HRQoL among people living with HIV on highly active antiretroviral therapy and factors associated with HRQoL in Ethiopia.

Methods

An institution-based cross-sectional study was conducted among 160 HIV–infected patients who were initiated highly active antiretroviral therapy at Jimma University Medical Center in 2016. HRQoL was assessed using the patient-reported outcome quality of life-HIV (PROQOL-HIV) measuring scale. Linear regressions were used to identify factors associated with outcome. Statistical significance was considered at p-value <0.05.

Results

Out of a total of 160 participants, 63.13% were females. The mean (±SD) age of study participants was 41.47±9.45 years. The median baseline CD₄+ cell count was 182.00 cells/µL (IQR: 104.53–262.40 cells/µL). The mean (±SD) score of PROQOL-HIV scale domains was 77.58 ±15.11, 58.32 ±7.79, 61.75± 17.95, 85.07 ±15.67, 76.92 ± 20.52, 80.00 ±16.83, 74.37 ± 1.47, 81.45 ± 8.17 for physical health and symptoms, emotional distress, health concerns, body change, intimate relationships, social relationships, stigma, and treatment impact domains, respectively. Second line antiretroviral therapy showed a negative effect on the quality of life, especially on the treatment impact domain (β=−6.301). Cotrimoxazole preventive therapy had a significant positive effect on the physical health and symptoms of HIV patients (β= +8.381, p<0.05). Advanced disease (β=−2.709, p<0.05), and non-communicable disease comorbidity (β=−14.340, p<0.001) showed a significant negative effect on physical health and symptoms.

Conclusion

Several behavioral, clinical & immunological factors were negatively associated with health-related quality of life. The double burden of chronic non-communicable disease(s) and the impact of treatment were highly significant in all dimensions of HRQoL measures. Therefore, with HRQoL emerging as a key issue for HIV–infected patients, its routine assessment and appropriate interventions at each clinic visit would be very crucial.

Health-related quality of life of HIV infected adults with and without Visceral Leishmaniasis in Northwest Ethiopia

BACKGROUND

Health-related quality of life (HRQoL) is an important outcome measure among HIV infected patients receiving antiretroviral therapy (ART). When HIV infected patients coinfected with Visceral Leishmaniasis (VL) the problem become severe because VL accelerates HIV replication and disease progression. The impact of VL on the quality of life of HIV infected patients has not been studied. In this study in Ethiopia, we compared the quality of life of HIV infected patients with and without VL.

METHODS

A cross-sectional study was conducted from October 2015 to September 2016 in selected health centers and hospitals, in Northwest Ethiopia. Data on quality of life was collected by trained nurses. The instrument used to collect the data was the short Amharic version of the World Health Organization Quality of Life for HIV clients (WHOQoL-HIV). Depression was assessed using the validated version of Kessler scale. Data was entered and analyzed using SPSS version 20. Descriptive statistics, bivariate and multivariate linear regression model was used to summarize the results.

RESULTS

A total of 590 study participants were included in the study with response rate of 95%. Of the 590 patients included in our study 125 (21%) were HIV-VL coinfection. HIV-VL coinfected patients had a lower quality of life in all the domains as compared to HIV patients without VL. Depression was consistently and strongly associated with all the quality of life domains of both groups. Also, in HIV infected patients a longer duration in ART was associated with higher HRQoL domains except for the spiritual and level of independence domains. With regard to HIV-VL coinfected patients, a longer duration in ART was associated with psychological, spiritual and level of independence domains of HRQoL. Demographics, clinical, and treatment characteristics resulted few significant associations with HRQoL domains of both groups.

CONCLUSION

HIV-VL coinfected patients had a poor quality of life in all the domains of the WHOQoL-HIV instrument. Depression, duration of ART and education were strongly associated with the quality of life. Depression should be targeted for intervention to improve the quality of life.

Unusual Response of Subclavian In-Stent Restenosis to Balloon Angioplasty in a Patient with HIV

Human Immunodeficiency Virus (HIV) infection and use of protease inhibitors have been associated with accelerated atherosclerosis. Increased rates of coronary in-stent restenosis are reported in these patients. There is limited data available on peripheral vascular disease interventions on these patients. Herein we report an aggressive subclavian in-stent restenosis with an unexpected response to balloon angioplasty treatment with a large, mobile tissue flap formation and its treatment with another stent.

Outcomes among HIV-1 infected individuals first starting antiretroviral therapy with concurrent active TB or other AIDS-defining disease

Background

Tuberculosis (TB) is common among HIV-infected individuals in many resource-limited countries and has been associated with poor survival. We evaluated morbidity and mortality among individuals first starting antiretroviral therapy (ART) with concurrent active TB or other AIDS-defining disease using data from the “Prospective Evaluation of Antiretrovirals in Resource-Limited Settings” (PEARLS) study.

Methods

Participants were categorized retrospectively into three groups according to presence of active confirmed or presumptive disease at ART initiation: those with pulmonary and/or extrapulmonary TB (“TB” group), those with other non-TB AIDS-defining disease (“other disease”), or those without concurrent TB or other AIDS-defining disease (“no disease”). Primary outcome was time to the first of virologic failure, HIV disease progression or death. Since the groups differed in characteristics, proportional hazard models were used to compare the hazard of the primary outcome among study groups, adjusting for age, sex, country, screening CD4 count, baseline viral load and ART regimen.

Results

31 of 102 participants (30%) in the “TB” group, 11 of 56 (20%) in the “other disease” group, and 287 of 1413 (20%) in the “no disease” group experienced a primary outcome event (p = 0.042). This difference reflected higher mortality in the TB group: 15 (15%), 0 (0%) and 41 (3%) participants died, respectively (p<0.001). The adjusted hazard ratio comparing the “TB” and “no disease” groups was 1.39 (95% confidence interval: 0.93–2.10; p = 0.11) for the primary outcome and 3.41 (1.72–6.75; p<0.001) for death.

Conclusions

Active TB at ART initiation was associated with increased risk of mortality in HIV-1 infected patients.

An educational intervention to reduce pain and improve pain management for Malawian people living with HIV/AIDS and their family carers: study protocol for a randomised controlled trial

Background

Many HIV/AIDS patients experience pain often due to advanced HIV/AIDS infection and side effects of treatment. In sub-Saharan Africa, pain management for people with HIV/AIDS is suboptimal. With survival extended as a direct consequence of improved access to antiretroviral therapy, the prevalence of HIV/AIDS related pain is increasing. As most care is provided at home, the management of pain requires patient and family involvement. Pain education is an important aspect in the management of pain in HIV/AIDS patients. Studies of the effectiveness of pain education interventions for people with HIV/AIDS have been conducted almost exclusively in western countries.

Methods/design

A randomised controlled trial is being conducted at the HIV and palliative care clinics of two public hospitals in Malawi. To be eligible, patient participants must have a diagnosis of HIV/AIDS (stage III or IV). Carer participants must be the individual most involved in the patient’s unpaid care. Eligible participants are randomised to either: (1) a 30-minute face-to-face educational intervention covering pain assessment and management, augmented by a leaflet and follow-up telephone call at two weeks; or (2) usual care. Those allocated to the usual care group receive the educational intervention after follow-up assessments have been conducted (wait-list control group). The primary outcome is pain severity measured by the Brief Pain Inventory. Secondary outcomes are pain interference, patient knowledge of pain management, patient quality of life, carer knowledge of pain management, caregiver motivation and carer quality of life. Follow-up assessments are conducted eight weeks after randomisation by palliative care nurses blind to allocation.

Discussion

This randomised controlled trial conducted in sub-Saharan Africa among people living with HIV/AIDS and their carers will assess whether a pain education intervention is effective in reducing pain and improving pain management, quality of life and carer motivation.

Trial registration

Current Controlled Trials ISRCTN72861423.

Change in quality of life: a follow up study among patients with HIV infection with and without TB in Ethiopia

Background

There is a dearth of literature on the impact of TB/HIV co-infection on quality of life (QoL). We conducted a study to assess the change in QoL over a 6-months period and its predictors among HIV-infected patients with and without TB in Ethiopia.

Methods

465 HIV-infected patients without TB and 124 TB/HIV co-infected patients were enrolled in a prospective study in February, 2009. 455 (98%) HIV-infected and 97 (78%) TB/HIV co-infected patients were followed for 6 months. Data on QoL at baseline and 6^th month were collected by trained nurses through face to face interviews using the short Amharic version of the World Health Organization Quality of Life Instrument for HIV clients (WHOQOL HIV-Brief). Common Mental Disorder (CMD) was assessed using a validated version of the Kessler-10 scale. Multivariate analysis was conducted using generalized estimating equations (GEE) using STATA to assess change in QoL and its predictors.

Results

There was a statistically significant improvement of the physical, psychological, social, environmental and spiritual QoL at the 6^th months follow up compared to the baseline for both groups of patients (P < 0.0001). The change in QoL in all dimension were more marked for TB/HIV co-infected patients compared to HIV-infected patients without TB.

A severe form of CMD was strongly associated with poorer physical QoL among TB/HIV co-infected individuals (β = −2.84; P = 0.000) and HIV clients without TB (β = −2.34; P = 0.000).

Conclusion

This study reveals that ART and anti-TB treatment significantly improve the QoL particularly among TB/HIV co-infected patients. We recommend that the ministry of health in collaboration with partners shall integrate mental health services into the TB/HIV programs and train health care providers to timely identify and treat CMD to improve QoL.

Low cerebrospinal fluid concentrations of the nucleotide HIV reverse transcriptase inhibitor, tenofovir

BACKGROUND

Tenofovir is a nucleotide HIV reverse transcriptase inhibitor whose chemical properties suggest that it may not penetrate into the central nervous system in therapeutic concentrations. The study's objective was to determine tenofovir's penetration into cerebrospinal fluid (CSF).

METHODS

CNS HIV Antiretroviral Therapy Effects Research is a multicenter observational study to determine the effects of antiretroviral therapy on HIV-associated neurological disease. Single random plasma and CSF samples were drawn within an hour of each other from subjects taking tenofovir between October 2003 and March 2007. All samples were assayed by mass spectrometry with a detection limit of 0.9 ng/mL.

RESULTS

One hundred eighty-three participants (age 44 ± 8 years; 83 ± 32 kg; 33 females; CSF protein 44 ± 16 mg/dL) had plasma and CSF samples drawn 12.2 ± 6.9 and 11 ± 7.8 hours post dose, respectively. Median plasma and CSF tenofovir concentrations were 96 ng/mL [interquartile range (IQR) 47-153 ng/mL] and 5.5 ng/mL (IQR 2.7-11.3 ng/mL), respectively. Thirty-four of 231 plasma (14.7%) and 9 of 77 CSF samples (11.7%) were below detection. CSF to plasma concentration ratio from paired samples was 0.057 (IQR 0.03-0.1; n = 38). Median CSF to wild-type 50% inhibitory concentration ratio was 0.48 (IQR 0.24-0.98). Seventy-seven percent of CSF concentrations were below the tenofovir wild-type 50% inhibitory concentration. More subjects had detectable CSF HIV with lower (≤ 7 ng/mL) versus higher (>7 ng/mL) CSF tenofovir concentrations (29% versus 9%; P = 0.05).

CONCLUSIONS

Tenofovir concentrations in the CSF are only 5% of plasma concentrations, suggesting limited transfer into the CSF, and possibly active transport out of the CSF. CSF tenofovir concentrations may not effectively inhibit viral replication in the CSF.

Palliative care for HIV in the era of antiretroviral therapy availability: perspectives of nurses in Lesotho

Background

Southern Africa is disproportionately affected by the HIV/AIDS epidemic. In Lesotho 23% of adults are HIV-positive, and only 26% of those in need are accessing antiretroviral treatment (ART). Consequently, about 18,000 people die from AIDS each year. In this situation, palliative care is needed towards the end of life, but is also recommended throughout the HIV disease trajectory. The World Health Organisation (WHO) has produced the Integrated Management of Adolescent and Adult Illness (IMAI) guidelines, which includes a palliative care guidebook (as well as acute and chronic ART guidebooks). IMAI aims to facilitate the implementation of integrated HIV/AIDS care in resource-poor areas. The opinions of health workers towards this integrated approach to care and the use of IMAI has not been considered in previous research studies. This paper therefore aims to address some of these issues.

Methods

Semi-structured interviews were conducted with six key informants and ten nurses in Lesotho. The interviews were transcribed verbatim and analysed using content thematic analysis.

Results

Many nurses described palliative care as synonymous with chronic care and felt that palliative care is necessary for HIV-positive patients despite the introduction of ART. It was thought that the approach taken should be holistic and integrated throughout the disease trajectory. Pain management was noted to be a particular area of need for palliative care, and it was suggested that this could be improved in Lesotho. The IMAI guidelines were thought to be useful, but knowledge of the palliative care booklet was limited.

Conclusion

Palliative care remains necessary for HIV despite the increasing availability of ART. However, it is currently significantly lacking in Lesotho and many other sub-Saharan African countries. Greater understanding of palliative care amongst health workers is required, as well as strong political will from the Ministry of Health. The IMAI guidelines are a useful tool for holistic HIV care, including palliative care, but they need to be used more effectively. As ART is becoming increasingly available worldwide, the complex chronic care issues for patients with HIV/AIDS should not be neglected.

Changes in the incidence and predictors of human immunodeficiency virus-associated dementia in the era of highly active antiretroviral therapy

OBJECTIVE

Though effective anti-human immunodeficiency virus (HIV) therapies are now available, they have variable penetration into the brain. We therefore aimed to assess changes over calendar time in the risk for HIV-associated dementia (HIV-D), and factors associated with HIV-D risk.

METHODS

Using Concerted Action on Seroconversion to AIDS and Death in Europe (CASCADE) data, we analyzed factors associated with time from HIV seroconversion to HIV-D using Cox models with time-updated covariates. The effect of duration of infection was explored using flexible parametric survival models.

RESULTS

222 of 15,380 seroconverters developed HIV-D. The incidence per 1,000 person-years was 6.49 pre-1997 (before highly active antiretroviral therapy was available), declining to 0.66 by 2003 to 2006. Compared with most recent CD4 count > or = 350 cells/mm3, the adjusted relative risk (95% confidence interval) of HIV-D was 3.47 (1.91-6.28), 10.19 (5.72-18.15), and 39.03 (22.96-66.36) at 200 to 349, 100 to 199, and 0 to 99 cells/mm3, respectively. In 2003 to 2006, older age at seroconversion (relative risk = 3.24 per 10-year increase [95% confidence interval, 2.00-5.24]) and previous acquired immune deficiency syndrome diagnosis (relative risk = 4.92 [95% confidence interval, 1.43-16.92]) were associated with HIV-D risk, independently of current CD4 count. HIV-D risk appeared to increase during chronic infection, by 48% at 10 years after seroconversion compared with the lowest risk at 1.8 years.

INTERPRETATION

HIV-D incidence has reduced markedly since 1997. However, patients with low (<200 cells/mm3) or even intermediate (200-349 cells/mm3) CD4 counts, previous acquired immune deficiency syndrome diagnosis, longer HIV infection duration, and older age at seroconversion are at increased risk and should be closely monitored for neurocognitive disorders.

[Anhedonia and depressive symptomatology among HIV-infected patients with highly active antiretroviral therapies (ANRS-EN12-VESPA)]

INTRODUCTION

Anhedonia is defined as the loss of the capacity to feel pleasure and there is no consensus with its relationship with depressive symptomatology. Furthermore, no study has investigated the problematic of anhedonia in the context of HIV-infection, which concern a lot of patients with depressive symptoms. Depressive symptomatology presents a major challenge in the management of HIV-infection due to its central role in clinical progression.

OBJECTIVE

This study aims to disentangle relationship between determinants of anhedonia, depression and anxiety in order to optimise mental management of HIV infection.

METHOD

In 2003, a face-to-face survey (ANRS-EN12-VESPA) was conducted among patients selected in a random stratified sample of 102 French hospital departments delivering HIV care. Eligible respondents were HIV-infected outpatients, aged 18 or older living in France and diagnosed for at least six months. Among solicited patients, 2932 agreed to participate (response rate: 59%) and data about anhedonia, anxiety and depression are available for 1427 patients. The face-to-face gathered information on sociodemographic characteristics, such as education level, gender, partner, children, financial situation or housing and also psychosocial and sociobehavioural characteristics, such as drug use. Self-reported side effects of treatment were also available.

ASSESSMENT TOOLS

Anxiety and depression were assessed using the hospital anxiety and depression (HAD) scale. Physical anhedonia was assessed using the French version of the Chapman scale. Three regression models were used to identify factors associated with anhedonia, anxiety and depression among demographic, psychosocial and clinical characteristics.

RESULTS

Factors independently associated with anhedonia were older age (>50), lower education level, unemployment and men HIV contaminated by heterosexual relation or injecting drug use. Women, with lower education level, unemployment, without steady partner, with a detectable viral load and who reported side effect of HAART presented more frequently anxiety. Unemployment, uncomfortable housing, no social support from friends, self-reported side effect and lipodystrophy were independently associated with depression.

CONCLUSION

Our results underline the multiplicity of factors associated with mental disorders related to depression. These results can be explained by the fact that the anxiety and anhedonia are two cardinal symptoms of depression. Determinants of anhedonia and anxiety reported in this study may provide the key to a more exact delineation of depressive disorders in the context of HIV infection in order to optimize long-term psychological follow up of concerned patients.

Time perspective and quality of life among HIV-infected patients in the context of HAART

We explored associations between time perspective (TP) and quality of life (QOL) among HIV-infected patients. With the French validated version of the Zimbardo Time Perspective Inventory, we evaluated the TP of patients. A self-administered questionnaire gathered information about QOL (WHOQOL-HIV), TP, relationship with medical staff and self-reported side effects of HAART. Six scores of QOL - physical, psychological, social relationship, environment, patient independence and spirituality were used as dependent variables in the linear regressions to identify factors associated with QOL. The sample (n=72) for this study was recruited from a hospital department specialising in HIV care and consisted of 48 (67%) HIV-infected women and 24 (33%) HIV-infected men with a mean age of 42 years. Using hierarchical regression analysis adjusted on socio-demographic characteristics, clinical characteristics and co-factors, significant relationships were observed between the several TP orientations and an impaired physical, environmental QOL as well as level-of-independence QOL. Specific dimensions of QOL are influenced by specific orientations of TP, which provides information on self-perception and subjective evaluation of QOL. The TP construct provides keys to managing HIV infection in order to improve QOL.

Frequency, determinants and consequences of delayed access to care for HIV infection in France

BACKGROUND AND OBJECTIVES

We analysed the frequency and predictors of delayed access to care (DAC) for HIV infection, and its influence on survival.

METHODS

We studied predictors of DAC among 18,721 patients enrolled between 1997 and 2002 in the French Hospital Database on HIV (FHDH), DAC being defined by a CD4* T-cell count below 200 copies/mm3 and/or AIDS at FHDH enrollment. The association of DAC with the initiation of combined antiretroviral therapy (cART) and of DAC with survival were analysed with Cox multivariable models.

RESULTS

The overall prevalence of DAC was 35.7%. Compared with patients under 30 years of age, patients over 60 were 3.5 times more likely to have DAC (P < 10(-4)). Compared with non-migrant women, odds ratios (OR) of DAC were higher among migrant women (1.5), non-migrant men (1.6) and migrant men (1.9; all P < 10(-4)). Compared with men who have sex with men, other transmission groups had an estimated OR for DAC of 1.6 (P < 10(-4)). DAC was more frequent among patients with a recent diagnosis of HIV infection [OR = 1.3, 95% confidence intervals (CI) = (1.2;1.4)]. Patients with DAC received cART earlier than other patients [hazard ratio (HR) = 2.2, 95% CI = (2.1;2.3)]. The DAC/mortality HR was 13.9 in the first 6 months after enrollment in the FHDH, and remained significantly higher than 1 during the subsequent 4 years.

CONCLUSION

DAC is common in France and was associated with a higher mortality, despite early initiation of cART. Earlier access to care and specific clinical management of patients with DAC should be considered.

Highly Active Antiretroviral Therapy Attenuates Re-Endothelialization and Alters Neointima Formation in the Rat Carotid Artery After Balloon Injury

Highly active antiretroviral therapy (HAART) has led to a sustained decline of HIV-associated morbidity and mortality. HAART exhibits significant side effects, however, such as hyperlipidemia and hyperglycemia, which possibly contribute to accelerated atherosclerosis in HAART-treated patients. In addition, direct effects of HAART on vascular cells have been described, which may promote atherosclerotic lesion formation. The effects of HAART on balloon-induced neointima formation have not been studied previously. The rat carotid artery balloon model was used to evaluate the effects of HAART (lopinavir, ritonavir, lamivudine, and zidovudine) on neointima formation and endothelial recovery. Furthermore, the effects of concomitant administration of the 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase inhibitor rosuvastatin were investigated. HAART-treated animals displayed an increase in lesion size (neointima/media ratio: 1.14 +/- 0.32 vs. 1.31 +/- 0.20 in control vs. HAART; P < 0.05) and an impaired regenerative capacity of the endothelium, as indicated by reduction in endothelial regrowth from an adjacent undilated vessel segment 14 days after injury (re-endothelialization area: 8.29 +/- 1.45 mm vs. 5.09 +/- 0.53 mm in control vs. HAART; P < 0.05). When rosuvastatin was given in addition to HAART, these effects were not observed. In conclusion, HAART inhibited endothelial cell-mediated healing and promoted neointima formation after angioplasty in rats. These deleterious effects were attenuated by cotreatment with rosuvastatin, however. Our studies suggest that currently used drug regimens against HIV infection may lead to an increased risk for restenosis after percutaneous vascular interventions. Moreover, the findings indicate that the additional treatment with statins might counteract these adverse effects by HAART.

Unsafe sex with casual partners and quality of life among HIV-infected gay men: evidence from a large representative sample of outpatients attending French hospitals (ANRS-EN12-VESPA)

INTRODUCTION

The introduction of highly active antiretroviral therapy has relaunched the debate on risky sexual behavior among HIV-infected gay men. It was proposed to study the influences of lifestyle characteristics and health-related quality of life (HRQL) on unsafe sex with casual partners in a representative sample of HIV-infected gay men.

METHODS

In 2003, a national survey based on face-to-face interviews was conducted among a representative sample of patients selected in a random stratified sample of 102 French hospital departments delivering HIV care. The patients selected for this analysis were gay men who reported having had sex with casual partners during the previous 12 months. Unsafe sex was defined as at least 1 episode of anal sexual intercourse without a condom with a casual partner during the previous 12 months. Health-related quality of life was assessed using the SF-36 Scale. Patients who declared that they had engaged in unsafe sex were compared with those who declared that they had not done so, using the chi test and logistic regressions.

RESULTS

Among the 1,117 gay men who participated in the study, 607 declared having had casual partners during the previous 12 months, and 140 (20%) of this latter group had engaged in unsafe sex. Poor mental HRQL was encountered in 68% of the patients and found to be independently associated with unsafe sex, even after multiple adjustment for number of partners, occurrences of binge drinking, use of anxiolytics, use of the Internet, and use of outdoor and commercial venues for sexual encounters.

CONCLUSIONS

Risky sexual behavior with casual partners is frequent among HIV-infected gay men. In addition to other well-known factors, behavior of this kind was found in this study to be related to poor mental HRQL. A more comprehensive approach to care designed to improve mental quality of life might therefore make for more effective secondary prevention.

Nevirapine uptake into the central nervous system of the Guinea pig: an in situ brain perfusion study

The presence of human immunodeficiency virus (HIV) in the central nervous system (CNS) is associated with the development of HIV-1-associated dementia (HAD), a major cause of HIV-related mortality. To eradicate HIV in the CNS, anti-HIV drugs need to reach the brain and cerebrospinal fluid (CSF) in therapeutic concentrations. This involves passage through the blood-brain and blood-CSF barriers. Using a well established guinea pig in situ brain perfusion model, this study investigated whether nevirapine [6H-dipyrido(3,2-b:2',3'-e)(1,4)diazepin-6-one,11-cyclopropyl-5,11-dihydro-4-methyl], a non-nucleoside reverse transcriptase inhibitor (NNRTI), could effectively accumulate in the CNS. [(3)H]Nevirapine was coperfused with [(14)C]mannitol (a vascular/paracellular permeability marker) through the carotid arteries for up to 30 min, and accumulation in the brain, CSF, and choroid plexus was measured. [(3)H]Nevirapine uptake into the cerebrum was greater than uptake of [(14)C]mannitol, indicating significant passage across the blood-brain barrier and accumulation into the brain (this was further confirmed with capillary depletion and high-performance liquid chromatography analyses). Likewise, [(3)H]nevirapine showed a great ability to cross the blood-CSF barrier and accumulate in the CSF, compared with [(14)C]mannitol. The CNS accumulation of [(3)H]nevirapine was unaffected by 100 muM nevirapine, suggesting that passage across the blood-brain barrier can occur by diffusion. Furthermore, coperfusion with 100 muM efavirenz [2H-3,1-benzoxazin-2-one, 6-chloro-4-(cyclopropylethynyl)-1,4-dihydro-4-(trifluoromethyl)-, (4S)-; another NNRTI] did not significantly alter CNS accumulation of [(3)H]nevirapine, indicating that the efficacy of nevirapine in the CNS would not be altered by the addition of this drug to a combination therapy. Together, these data indicate that this anti-HIV drug should be beneficial in the eradication of HIV within the CNS and the subsequent treatment of HAD.

Partial treatment interruption of protease inhibitor-based highly active antiretroviral therapy regimens in HIV-infected children

Treatment guidelines for HIV-infected children recommend using combinations of reverse transcriptase inhibitors (RTIs) and protease inhibitors (PIs). Successful suppression of HIV replication and adherence to these regimens are often suboptimal because of multiple factors. For patients with detectable viremia and limited treatment options, therapy simplification consisting of RTIs, referred to as partial treatment interruption (PTI), may represent a temporizing option. We describe a cohort of 26 HIV-infected children who underwent treatment simplification by discontinuing the PI and continuing therapy with 2 or more RTIs. The subjects, who were identified retrospectively, were followed for a period of 24 to 96 weeks. Data collected included clinical information, viral load, and CD4T lymphocyte percentage (CD4%) at baseline and 24, 48, and 96 weeks after PTI. Twenty-six, 21, and 11 patients were evaluated at 24, 48, and 96 weeks, respectively. No child had Centers for Disease Control and Prevention-defined disease progression, and there were no significant changes in viral loads (P > 0.5) across all study intervals after interruption of the PIs. Although most children maintained a CD4% > 15%, comparisons of CD4% at 24 and 48 weeks demonstrated a statistically significant decrease compared with baseline. Therapy simplification by PTI may provide a practical option in patients intolerant of or failing PI-based highly active antiretroviral therapy.

Cutaneous manifestations of HIV in the era of highly active antiretroviral therapy: An institutional urban clinic experience

BACKGROUND

Widespread introduction of highly active antiretroviral therapy (HAART) in the mid 1990s has altered the presentation of the cutaneous manifestations associated with HIV infection.

OBJECTIVE

Our purpose was to evaluate the use of HAART on the prevalence and spectrum of cutaneous manifestations in HIV-infected patients.

METHODS

A study of the initial visits of 897 HIV-infected patients at an urban dermatology clinic between 1996 and 2002 was performed.

RESULTS

Folliculitis was the most common cutaneous disorder identified. Patients with CD4-positive cell counts less than 200 cells/mm3 had an increased prevalence of folliculitis and prurigo nodularis, whereas those with HIV viral loads higher than 55,000 copies/mL had a higher prevalence of idiopathic pruritus and candidiasis. Patients not receiving HAART had increased rates of folliculitis and prurigo nodularis. Patients receiving HAART had increased rates of photosensitivity and molluscum contagiosum.

LIMITATIONS

This was a cross-sectional study in which temporality was unable to be determined.

CONCLUSION

With ongoing therapeutic advancements, the cutaneous manifestations associated with HIV infection will continue to evolve.

The distribution of the anti-HIV drug, tenofovir (PMPA), into the brain, CSF and choroid plexuses

Background

Tenofovir disoproxil fumarate, a prodrug of the nucleotide reverse transcriptase inhibitor, tenofovir (9-[9(R)-2-(phosphonomethoxy)propyl]adenine; PMPA), was recently approved for use in the combination therapy of human immunodeficiency virus (HIV)-1 infection. This study was undertaken to understand PMPA distribution to the virus sanctuary sites located in the brain, CSF and choroid plexuses and to clarify its possible role in reducing the neurological problems associated with HIV infection.

Methods

The methods used included an established bilateral carotid artery perfusion of [³H]PMPA and a vascular marker, D-[¹⁴C]mannitol, in anaesthetised guinea-pigs followed by scintillation counting, HPLC and capillary depletion analyses. Movement of [³H]PMPA into the brain, cisternal CSF and lateral ventricle choroid plexus was also examined in the absence and presence of additional anti-HIV drugs and a transport inhibitor. Control and test groups were compared by ANOVA or Student's t-test, as appropriate.

Results

The distribution of [³H]PMPA in the cerebrum, cerebellum, pituitary gland and cerebral capillary endothelial cells was not significantly different to that measured for D-[¹⁴C]mannitol. However, [³H]PMPA accumulation was significantly higher than that of D-[¹⁴C]mannitol in the choroid plexus and CSF. Further experiments revealed no cross-competition for transport of [³H]PMPA by probenecid, a non-specific inhibitor of organic anion transport, or the nucleoside reverse transcriptase inhibitors into any of the CNS regions studied. The octanol-saline partition coefficient measurement for [³H]PMPA was 0.0134 ± 0.00003, which is higher that the 0.002 ± 0.0004 measured for D-[¹⁴C]mannitol in an earlier study.

Conclusion

There is negligible transport of [³H]PMPA across the blood-brain barrier, but it can cross the blood-CSF barrier. This is a reflection of the differing physiological and functional characteristics of the blood-CNS interfaces. Self- and cross-inhibition studies did not suggest the involvement of a transport system in the CNS distribution of this drug. However, the ability of PMPA to accumulate in the choroid plexus tissue, but not the cerebral capillary endothelial cells, and the hydrophilic nature of PMPA, does point to the possibility of a transporter at the level of the choroid plexus. PMPA that has crossed the choroid plexus and is in the CSF could treat HIV-infected perivascular and meningeal macrophages, but it is unlikely to reach the infected microglia of deep brain sites.

Barriers to HIV-testing among Hispanics in the United States: analysis of the National Health Interview Survey, 2000

Data from the 2000 National Health Interview Survey (NHIS) were analyzed to explore barriers to HIV testing, and intentions to be tested among a nationally representative sample (n = 4,261) of the different Hispanic subgroups living in the United States. Weighted proportions and variances accounting for the complex sample design of the NHIS were estimated using the Taylor series linearization method. Regression estimates are expressed as odds ratios and their 95% confidence intervals. Two thirds of sampled Hispanics had never been tested for HIV (excluding blood donations) and 88% expressed no intention to do so in the near future. Many of the factors that influence the likelihood of having been tested in the past also impact on future HIV testing intentions including age, Hispanic subgroup, high-risk status, and self-perceived HIV risk. Compared to Puerto Ricans, Mexicans (odds ratio [OR] = 1.59, 1.1-2.3) and Mexican/Americans (OR = 1.61, 1.1-2.3) were more likely to never have been tested and Cubans were notably more likely to report negative future testing intentions (OR = 5.63, 2.5-12.8). Among Hispanics who reported high-risk status or high/medium self-perceived HIV risk, more than one quarter had never undergone testing and expressed no intention of doing so in the near future. Recognition of the HIV testing barriers identified in this study is valuable for the development and refinement of current strategies that aim to increase HIV testing practices in the heterogeneous U.S. Hispanic population.

Changing mortality rates and causes of death for HIV-infected individuals living in Southern Alberta, Canada from 1984 to 2003

OBJECTIVES

To examine changes over a 2-year period in both the mortality rate and the causes of death in a geographically defined HIV-infected population.

METHODS

A database search of primary care information for the dates and causes of death for all patients documented with HIV infection and living in Southern Alberta between 1984 and 2003 was undertaken. Sociodemographic and clinical characteristics were obtained. Causes of death were then individually confirmed by reviewing the patients' hospital charts, autopsy reports, or death certificates and coded using the International Classification of Diseases, 9th Revisions. AIDS deaths were reconciled with Public Health Reports. The time span was divided into pre-highly active antiretroviral therapy (HAART) (1984-1996) and current HAART (1997-2003) periods.

RESULTS

Between 1984 and 2003, there were 560 deaths in the 1987 individuals living with HIV infection in Southern Alberta. Of these, 436 deaths (78%) occurred pre-HAART and 124 (22%) in the current HAART period. The crude mortality rate declined from 117 deaths per 1000 patient-years pre-HAART to 24 in the current HAART period. In the pre-HAART era, 90% of all deaths were AIDS related whereas only 67% were AIDS related in the current HAART era. The leading causes of AIDS deaths were AIDS multiple causes (31%), Mycobacterium avium complex (18%), Pneumocystis pneumonia (10%) and non-Hodgkin's lymphoma (7%). The proportion of non-AIDS related deaths increased from 7% pre-HAART to 32% in the current HAART era. Accidental deaths, including drug overdose (29%), suicide (7%) and violence (3%), hepatic disease (19%), non-AIDS related malignancies (19%), and cardiovascular disease (16%) accounted for the majority of non-AIDS related deaths. No deaths directly caused by drug toxicity were found. Overall, 21% of patients who died were antiretroviral (ARV)-naive. A total of 14% of patients dying from AIDS were ARV-naive in contrast to 35% dying from non-HIV related conditions. Of all those dying from AIDS, 23% died<3 months after their initial diagnosis, reflecting late presentation. In the current HAART era, 87% of patients who died from AIDS were extensively treated, reflecting HAART treatment failures due mostly to multiclass drug resistance (42%), inexorable disease progression despite ARV (32%), lack of ability or interest to be maintained on a lifelong HAART programme (21%) and, rarely, drug intolerance (<1%).

CONCLUSIONS

Deaths from AIDS-related causes have decreased significantly, but deaths from non-AIDS related conditions have increased, both as an absolute number of deaths and as a proportion of all deaths in HIV-infected patients. The increasing age of the HIV population, and the increased mean CD4 count, increased proportion of intravenous drug users, increased hepatitis B virus and hepatitis C virus coinfection rate, and increased history of smoking seen in our population also influenced the mortality rate and causes of death. These factors must also be considered in projecting future trends in mortality of an HIV-infected population.

Palliative care in sub-Saharan Africa

Control of pain and symptoms and terminal care are necessary for quality HIV and cancer care in sub-Saharan Africa. However, what constitutes feasible, accessible, and effective palliative care, and how to develop such services, remains to be resolved. Africa-specific palliative care includes components that carry resource implications. Home and community-based care has been largely successful, but community capacity and the resources and clinical supervision necessary to sustain quality care are lacking. Coverage and referrals must be primary concerns. Simple lay and professional protocols have been developed, but opioid availability remains a major constraint. Areas of good practice, and areas where further success may be achieved include: attention to community needs and capacity; explicit frameworks for service development and palliative-care integration throughout the disease course (including antiretroviral provision); further education and protocols; strengthening and dissemination of diverse referral and care systems; increasing advocacy; and funding and technical skills to build audit and quality assessment.

Access and equity in HIV/AIDS palliative care: a review of the evidence and responses

The high prevalence of pain and other symptoms throughout the HIV disease trajectory, the need for management of side effects related to antiretroviral therapy, the continuing incidence of cancers and new emerging co-morbidities as a result of extended life expectancy under new therapeutic regimes, and the ongoing need for terminal care all prove the curative versus palliative dichotomy to be inappropriate. Although there is evidence for both need and effectiveness of palliative care in HIV patient care, access is often poor and care less than optimal. This review aimed to identify evidence of barriers and inequalities in HIV palliative care in order to inform policy and service development. Biomedical databases were searched using a specific strategy, and evidence extracted into the barrier and inequity categories of patient, clinician, service and disease factors. A model of the barriers and inequalities is presented from the evidence. Recommendations are made from the evidence for promoting access and outcomes through integrated palliative care from diagnosis to end-of-life, alongside antiretroviral therapy when initiated. Service responses that have attempted to increase access to palliative care are presented.

Does palliative care improve outcomes for patients with HIV/AIDS? A systematic review of the evidence

BACKGROUND

The need for palliative care in HIV management is underlined by the high prevalence of pain and symptoms, the toxicity, side effects, and virological failure associated with antiretroviral therapy, emergence of co-morbidities, continued high incidence of malignancies, late presentation of people with HIV disease, and the comparatively higher death rates among the infected individuals.

METHODS

A systematic review was undertaken to appraise the effect of models of palliative care on patient outcomes. A detailed search strategy was devised and biomedical databases searched using specific terms relevant to models of palliative care. Data from papers that met the inclusion criteria were extracted into common tables, and evidence independently graded using well described hierarchy of evidence.

RESULTS

34 services met the inclusion criteria. Of these, 22 had been evaluated, and the evidence was graded as follows: grade 1 (n = 1); grade 2 (n = 2); grade 3 (n = 7); grade 4 (n = 1); qualitative (n = 6). Services were grouped as: home based care (n = 15); home palliative care/hospice at home (n = 7); hospice inpatient (n = 4); hospital inpatient palliative care (n = 4); specialist AIDS inpatient unit (n = 2); and hospital inpatient and outpatient care (n = 2). The evidence largely demonstrated that home palliative care and inpatient hospice care significantly improved patient outcomes in the domains of pain and symptom control, anxiety, insight, and spiritual wellbeing.

CONCLUSIONS

Although the appraisal of evidence found improvements across domains, the current body of evidence suffers from a lack of (quasi) experimental methods and standardised measures. The specialism of palliative care is responding to the clinical evidence that integration into earlier disease stages is necessary. Further studies are needed to both identify feasible methods and evaluate the apparent beneficial effect of palliative care on patient outcomes in the post-HAART era.

Emerging viral infections

"Emerging infections" have been defined as infections that have newly appeared, that have appeared previously but are expanding in incidence and geographic range, or that threaten to increase in the near future. This article focuses on nine emerging viral infectious agents. These viruses illustrate how such agents emerge: by encroaching on previously unvisited habitats (eg, hantaviruses), by air travel (eg, SARS), and by accidental importation (eg, monkeypox). Additionally, the example of SARS demonstrates not only how quickly emerging viral infections can spread but also how quickly they can be identified and contained with motivated cooperation.