Complementary medicine use among people living with HIV/AIDS in Victoria, Australia: practices, attitudes and perceptions

There is limited evidence suggesting the underlying reasons for the use of complementary and alternative medicines (CAMs) by people with HIV/AIDS, or individual attitudes and beliefs about the use of CAMs. Using focus groups and a survey with 151 individuals attending the HIV Clinics at The Alfred Hospital, Melbourne, we aimed to provide insights into factors that influence the use of CAMs among people living with HIV/AIDS. Roughly half (49%) of the participants had used CAMs to manage their HIV/AIDs. Users of CAMs utilized a wide range of treatments in managing their condition, but costs of the CAMs meant that users were not necessarily able to use them as much as they might have liked. Use of CAMs was based on a desire to find something beneficial rather than on being dissatisfied with conventional medicine. Further research is needed into (a) the effects of CAMs and (b) the enhancement of communication and collaboration between patients, doctors and complementary medicine practitioners.

Prolonged use of tenofovir in HIV/hepatitis B virus (HBV)-coinfected individuals does not lead to HBV polymerase mutations and is associated with persistence of lamivudine HBV polymerase mutations

OBJECTIVES

The aim of the study was to identify and characterize hepatitis B virus (HBV) polymerase gene mutations associated with ongoing HBV replication in HIV/HBV-coinfected individuals receiving tenofovir (TDF).

METHODS

This retrospective cross-sectional study identified 28 HIV/HBV-coinfected individuals who had received TDF for at least 3 months. All patients had samples available while receiving TDF (on-TDF), and 24 also had samples available prior to treatment (pre-TDF). Case records were reviewed to obtain clinical and virological data at the times of sampling (+/-3 months). The HBV DNA of all samples was amplified using polymerase chain reaction (PCR), and the polymerase region of PCR-positive samples was sequenced and compared with reference HBV data.

RESULTS

Of the pre-TDF samples, 15 of 24 (63%) were HBV PCR positive. Of the on-TDF samples, four of 28 (14%) were HBV PCR positive (mean time on TDF 13.5 months; range 3-23 months). Lamivudine (3TC)-resistance mutations were detected in three of four (75%) of these viraemic samples. The previously identified putative TDF-resistance mutations, rtA194T+rtL180M+rtM204V, were not detected in any individual.

CONCLUSIONS

Unique mutations in the HBV polymerase gene associated with TDF resistance are rare in HIV/HBV coinfection. 3TC-resistance mutations persist and a significant proportion of patients are HBV PCR positive despite the addition of TDF.

Increased health care utilization and increased antiretroviral use in HIV-infected individuals with mental health disorders

OBJECTIVES

The aims of the study were to describe the prevalence and associations of mental health disorder (MHD) among a cohort of HIV-infected patients attending the Victorian HIV/AIDS Service between 1984 and 2000, and to examine whether antiretroviral therapy use or mortality was influenced by MHD (defined as a record of service provision by psychiatric services on the Victorian Psychiatric Case Register). It was hypothesized that HIV-positive individuals with MHD would have poorer treatment outcomes, reduced responses to highly active antiretroviral therapy (HAART) and increased mortality compared with those without MHD.

METHODS

This is a retrospective cohort of 2981 individuals (73% of the Victorian population diagnosed with HIV infection) captured on an HIV database which was electronically matched with the public Victorian Psychiatric Case Register (VPCR) (accounting for 95% of public system psychiatry service provision). The prevalence, dates and recorded specifics of mental health disorders at the time of the electronic match on 1 June 2000 are described. The association with recorded MHD, gender, age, AIDS illness, HIV exposure category, duration and type of antiviral therapy, treatment era (prior to 1986, post-1987 and pre-HAART, and post-HAART) on hospitalization and mortality at 1 September 2001 was assessed.

RESULTS

Five hundred and twenty-five individuals (17.6% of the Victorian HIV-positive population) were recorded with MHD, most frequently coded as attributable to substance dependence/abuse or affective disorder. MHD was diagnosed prior to HIV in 33% and, of those diagnosed after HIV, 93.8% were recorded more than 1 year after the HIV diagnosis. Schizophrenia was recorded in 6% of the population with MHD. Hospitalizations for both psychiatric and nonpsychiatric illness were more frequent in those with MHD (relative risk 5.4; 95% confidence interval 3.7, 8.2). The total number of antiretrovirals used (median 6.4 agents vs 5.5 agents) was greater in those with MHD. When adjusted for antiretroviral treatment era, HIV exposure category, CD4 cell count and antiretroviral therapy, survival was not affected by MHD.

CONCLUSIONS

MHD is frequent in this population with HIV infection and is associated with increased healthcare utilization but not with reduced survival.

Virological and immunological outcomes at 3 years after starting antiretroviral therapy with regimens containing non-nucleoside reverse transcriptase inhibitor, protease inhibitor, or both in INITIO: open-label randomised trial

BACKGROUND

Antiretroviral therapy has greatly reduced HIV mortality and morbidity. However, the best sequence of regimens and implications of initial regimen for long-term therapeutic success are not well defined.

METHODS

In INITIO, a large international randomised trial, we compared antiretroviral therapy with two nucleoside analogue reverse transcriptase inhibitors (didanosine+stavudine) plus either a non-nucleoside reverse transcriptase inhibitor (efavirenz, EFV) or a protease inhibitor (nelfinavir, NFV), or both (EFV/NFV), in patients with HIV-1 infection who had not previously received antiretroviral drugs. Primary outcomes were proportion with undetectable HIV RNA in plasma, and change in CD4 count from baseline at 3 years. Analyses were by intention-to-treat. This study is registered as an International Standard Randomised Controlled Trial, number ISRCTN44582462.

FINDINGS

We followed up 911 participants (297 EFV, 311 NFV, 303 EFV/NFV). At 3 years, the proportion with HIV RNA less than 50 copies per mL was highest in the EFV group (188 [74%] EFV, 162 [62%] NFV, 155 [62%] EFV/NFV; p=0.004). Mean (95% CI) increases in CD4 count were 316x10(6) cells per L (288-343) for EFV, 289x10(6) cells per L (262-316) for NFV, and 274x10(6) cells per L (231-291) for EFV/NFV (p=0.1). Fewer participants in the EFV group than in the other groups stopped adequate antiretroviral therapy for more than 30 days (p=0.005). Participants in the EFV/NFV group had shorter time to stopping the initial regimen (p<0.0001) and to a treatment modifying adverse event (p=0.04) than those in the other groups.

INTERPRETATION

Starting antiretroviral therapy with a three-drug/two-class regimen including efavirenz was better than starting with regimens including nelfinavir or efavirenz plus nelfinavir in terms of virological suppression and durability of the initial regimen. The shorter time on adequate antiretroviral therapy or to a treatment-modifying adverse event might explain the absence of additional benefit for the four-drug regimen.

Cohort analysis of two multidisciplined adherence intervention programmes for patients on antiretroviral therapy

The aim was to analyse data from two randomized controlled trials (RCTs) to determine if an adherence intervention programme for antiretroviral therapy (ART) resulted in a reduction in viral load. A cohort analysis of pre- and post-intervention viral loads and CD4 counts using paired analysis was undertaken on participants who received the intervention programme. Analysis was also undertaken on a control group. The intervention participants had an increase in mean CD4 count (450-478, P = 0.26), and a decline in log viral load (2.48-2.36, P = 0.056). The control group had a decline in mean CD4 counts (596-570, P = 0.53), and an increase in log viral load (2.09-2.11, P = 0.78). The use of an adherence intervention programme is associated with a decrease in mean viral load, which is in contrast to the control group that demonstrated an increase in viral load over time.

Depression and neurocognitive performance in individuals with HIV/AIDS: 2-year follow-up

OBJECTIVES

The aims of this study were to follow a cohort of HIV-infected individuals for 2 years to assess changes in depression and neuropsychological performance over time, to explore the relationship between depression, HIV illness and neuropsychological performance, and to examine the natural history of the effect of highly active antiretroviral therapy (HAART) on depression and neurocognitive performance.

METHODS

HIV-seropositive out-patients were assessed at baseline and at 2-year follow-up. At each assessment, patients were assessed for depression [using the Beck Depression Inventory (BDI) and Structured Clinical Interview (SCID-CV)] and completed a battery of neuropsychological tests including the Cambridge Neuropsychological Test Automated Battery (CANTAB) and the Hopkins HIV Dementia Scale (HDS).

RESULTS

At baseline, 34.8% scored > or =14 on the BDI [> or =14 suggests depressive symptoms (DS)]. The SCID-CV revealed that 27% of participants met the criteria for current mood disorder. Seven per cent of the participants' scores on the HDS indicated HIV-associated cognitive changes. Eighty participants were re-tested at 2-year follow-up and were split into two groups based on BDI scores at baseline. CANTAB results revealed that the cohort were significantly impaired on nine of 10 measures compared with age-matched normative data. Neurocognitive performance significantly improved for participants with no DS at baseline, whereas participants with DS at baseline did not show as much improvement. Multivariate analysis revealed that 40% of the change in cognitive performance was attributable to the variables age, AIDS and HAART regimen.

CONCLUSION

These results suggest a significant decline in depression scores and an improvement in several neurocognitive domains over time, with a relationship between HIV illness, HAART, symptoms of depression and neurocognitive performance.

Breast milk pasteurisation in developed countries to reduce HIV transmission. Do the benefits outweigh the risks?

BACKGROUND: Transmission of HIV through breastfeeding is well documented. The World Health Organisation advise HIV-infected women in developed countries to use alternatives to breastfeeding together with highly active antiretroviral therapy and optimal management of delivery to prevent transmission of HIV to their infant. CASE REPORT: We present the case of an HIV-infected woman electing to exclusively breastfeed for six months and applying milk pasteurisation techniques without transmission to her infant. Two paired samples of her breast milk were tested for HIV RNA prior to and after pasteurisation. The first pair of specimens reported no change in HIV RNA copy number, the second pair of specimens reported an increase in copy number. DISCUSSION: This technique, the evidence for HIV inactivation and the effects pasteurisation has on nutritional and immunological components of breast milk are discussed. CONCLUSION: In conclusion, we believe there is currently insufficient data to recommend this technique either as a safe alternative to formula feeding in resource-rich countries or as a method for providing intact immunological components of breast milk to the infant.

A randomised controlled trial of omega-3 fatty acid supplementation for the treatment of hypertriglyceridemia in HIV-infected males on highly active antiretroviral therapy

Background: Hypertriglyceridaemia is a recognised metabolic abnormality in HIV-infected people, increasing in severity in people treated with highly active antiretroviral therapy (HAART). An alternative treatment for hypertriglyceridaemia in non-HIV-infected populations is omega-3 fatty acid supplementation. This study aimed to compare the effectiveness of omega-3 fatty acid supplementation and placebo in lowering fasting triglyceride levels in HIV-infected patients on HAART. Methods: A placebo-controlled, randomised, double-blind trial in participants on stable HAART with fasting triglycerides of >3.5 mm to 10.0 mm using 9 g of omega-3 fatty acids versus placebo (olive oil) after a 6-week lead in on dietary therapy. Results: Eleven patients were enrolled. The mean triglyceride level for the population decreased from 5.02 mm at baseline to 4.44 mm (–11.6%) after dietary intervention and 3.37 mm (–32.9%) after the 8-week treatment period. In the omega-3 fatty acid arm of the study, triglycerides fell from 5.34 mm to 5.02 mm (–6%) after dietary intervention and to 2.30 mm (–56.9%) after the treatment period. In the placebo arm of the study, triglycerides fell from 4.77 mm to 4.05 mm (–15.1%) after dietary intervention and to 4.08 mm (–14.5%) after the treatment period. Using the random effects model, a statistically significant effect on triglycerides of omega-3 fatty acid versus placebo was found (χ2 = 6.04, P = 0.0487). The estimated difference between groups for change in mean triglycerides over 8 weeks was –2.32 mm (95% CI –4.52, –0.12 mm). Conclusions: Omega-3 fatty acids are likely to be an effective treatment for hypertriglyceridaemia in HIV-infected males on HAART.

Multidisciplinary HIV adherence intervention: a randomized study

Maintaining greater than 95% adherence to antiretroviral medication is necessary in order to have the greatest therapeutic impact on HIV infection. Furthermore, evidence suggests that adherence rates of between 70% and 89% are significantly associated with viral rebound and the development of drug resistance. Adherence rates at and above the 95% level are difficult for patients to achieve and maintain. Our aim was to determine if an adherence intervention could improve adherence among patients attending an ambulatory care clinic at a large public hospital. The intervention was delivered by a multidisciplinary team of health care professionals and consisted of education coupled with the provision of devices designed to assist patient memory and adherence. A crucial component of the intervention consisted of the identification of patient specific barriers to adherence and the development of strategies to circumvent these problems. Adherence was assessed using patient self-report over the past 4, 7, and 28 days and by calculation of the Morisky score. The study was conducted as a randomised controlled trial using the stepped wedge design with a total of 68 subjects randomised to receive the intervention over a 20-week period. Adherence before and after the intervention formed the analysis. There was a significant decrease in the number of missed doses over the past 4 (1.9 to 1.0, p < 0.001), 7 (3.0 to 1.8, p < 0.001) and 28 (7.4 to 4.2, p < 0.001) days and a decrease in the Morisky score, indicating an improvement in medication taking behaviour (1.3 to 0.5 p < 0.001).

Randomized trial of an adherence programme for clients with HIV

Our aim was to determine if a comprehensive adherence package improved self reported adherence to antiretroviral therapy. The adherence package included an education programme, individualized planning of regimens, and the opportunity for a patient to choose from a number of adherence aids and reminder devices. A randomized step wedge design was used. Forty-three individuals were randomized to begin the intervention over a five-month period. There was a substantial fall in the number of missed doses reported for the last four days (0.76 to 0.38, P =0.03) and last seven days (1.5 to 0.74, P =0.005) but not for the last 28 days (2.5 to 2.5, P =0.63). There was no statistical difference in the viral load or CD4 lymphocyte count in the period before or after the intervention. The Morisky score during the pre and post intervention periods was significantly different (P =0.006), 2.9 (SD 0.9) and 3.3 (SD 0.8) respectively. This adherence package improved self reported adherence during the last four and seven days.

Use of assisted reproductive technology to reduce the risk of transmission of HIV in discordant couples wishing to have their own children where the male partner is seropositive with an undetectable viral load

The advances in treatment of HIV and the introduction of polymerase chain reaction assay for the virus now make it acceptable for HIV discordant couples where the male partner is seropositive to attempt to conceive through artificial insemination by husband (AIH) or via in vitro fertilisation. With undetectable viral load and washed sperm, there is minimal risk of transmission of HIV to the female partner, children, other patients, or staff. We describe the development of a programme of AIH for HIV discordant couples and the reasoning behind offering such a programme.

HIV Lipodystrophy Case Definition using Artificial Neural Network Modelling

Objective

A case definition of HIV lipodystrophy has recently been developed from a combination of clinical, metabolic and imaging/body composition variables using logistic regression methods. We aimed to evaluate whether artificial neural networks could improve the diagnostic accuracy.

Methods

The database of the case-control Lipodystrophy Case Definition Study was split into 504 subjects (265 with and 239 without lipodystrophy) used for training and 284 independent subjects (152 with and 132 without lipodystrophy) used for validation. Back-propagation neural networks with one or two middle layers were trained and validated. Results were compared against logistic regression models using the same information.

Results

Neural networks using clinical variables only (41 items) achieved consistently superior performance than logistic regression in terms of specificity, overall accuracy and area under the ROC curve. Their average sensitivity and specificity were 72.4 and 71.2%, as compared with 73.0 and 62.9% for logistic regression, respectively (area under the ROC curve, 0.784 vs 0.748). The discriminating performance of the neural networks was largely unaffected when built excluding 13 parameters that patients may not have readily available. The average sensitivity and specificity of the neural networks remained the same when metabolic variables were also considered (total 60 items) without a clear advantage against logistic regression (overall accuracy 71.8%). The performance of networks considering also body composition variables was similar to that of logistic regression (overall accuracy 78.5% for both).

Conclusions

Neural networks may offer a means to improve the discriminating performance for HIV lipodystrophy, when only clinical data are available and a rapid approximate diagnostic decision is needed. In this context, information on metabolic parameters is apparently not helpful in improving the diagnosis of HIV lipodystrophy, unless imaging and body composition studies are also obtained.

Adherence to antiretroviral therapy: are we doing enough?

Adherence to antiretroviral therapy is a powerful predictor of response to therapy. For optimal antiretroviral therapy response, individuals need to take more than 95% of their prescribed medication. The most widely used method for measuring adherence is self-report of the number of missed doses and this should be done at every clinic visit. There are several well-recognized predictors of poor adherence, such as illicit drug use, depression, limited knowledge or ambivalence about starting treatment. Adherence can be improved by addressing these issues or through other means such as pill boxes or electronic reminders.

Non-tropical thoraco-abdominal pyomyositis caused by group A streptococcus in an immunocompetent adult

We present a case of group A streptococcal pyomyositis of the thoraco-abdominal wall of an immunocompetent adult. This diagnosis was made when soft tissue swelling was seen on chest X-ray. Complete recovery followed drainage of the collection and short-course i.v. penicillin. The importance, diagnosis and treatment of pyomyositis are outlined.

Suicidal behaviour in people with HIV/AIDS: a review

OBJECTIVE

To review the existing literature on suicidal behaviour in people with HIV/AIDS infection.

METHOD

A search on the Index Medicus/MEDLINE database was performed, for articles that investigated and/or reviewed suicidal behaviour in people with HIV at any stage of the illness. Only articles written in English were used in this review.

RESULTS

Most studies have been done on homosexual/bisexual groups, with little data available for heterosexual populations or women. Studies show an increased rate of suicidal ideation, suicide attempts and completed suicide in individuals with HIV/AIDS. Of note, there is a high prevalence of psychiatric illness and substance abuse in those with suicidal behaviour.

CONCLUSIONS

The increased rate of suicidal behaviour in HIV-infected persons is consistent with findings in other medically ill groups with chronic, life-threatening disorders. However, assessment of any possible direct effect of HIV/AIDS on suicidal behaviour is confounded by methodological limitations of many of the studies. More longitudinal studies encompassing other affected groups including heterosexual populations and women are needed to elucidate the relationship between suicidal behaviour and HIV/AIDS.

Quantification of mitochondrial DNA in peripheral blood mononuclear cells and subcutaneous fat using real-time polymerase chain reaction

BACKGROUND

With decreased rates of HIV mortality and disease progression attributable to treatment with nucleoside analogue reverse transcriptase inhibitors (NRTIs), attention has now become focused on the toxicities of these forms of treatment. It is believed NRTIs cause a decrease in mitochondrial DNA (mtDNA) synthesis due to their inhibition of DNA polymerase gamma. This hypothesis is supported by in vitro data from muscle biopsies and human lymphoblastic cell lines. The resulting mitochondrial toxicity is thought to manifest itself in a variety of clinical symptoms including fatigue, fat wasting and peripheral neuropathy. A non-invasive test of mitochondrial toxicity is needed to assess toxicity and optimise HIV treatment strategies. Peripheral blood mononuclear cells (PBMC) and subcutaneous fat could be ideal and accessible sources of mtDNA for examining toxicity.

OBJECTIVES

The objectives of this study were (a) to develop an assay to quantify the mtDNA copy number of PBMC and obtain reproducible results and (b) to establish the utility of subcutaneous fat as a source of mtDNA for quantification.

STUDY DESIGN

PBMC were isolated from blood by centrifugation over Ficoll-Paque and subcutaneous fat was obtained from two 3 mm punch skin biopsies. Following DNA extraction, the mtDNA copy number in each sample was quantified by real-time polymerase chain reaction (PCR).

RESULTS

The real-time PCR assay was found to generate consistent and reproducible results with replicates of samples undertaken within the same run, and in two or more different runs, having a mean coefficient of variation of 11.3 and 17.2%, respectively. PBMC and subcutaneous fat contained 409+/-148 and 2042+/-391 copies of mtDNA per cell, respectively.

CONCLUSIONS

From the work carried out it can be concluded that firstly, the real-time PCR assay generates consistent and reproducible results, and secondly that mtDNA can be extracted and quantified from PBMC and subcutaneous fat.

Comparison of genotyping and phenotyping methods for determining susceptibility of HIV-1 to antiretroviral drugs

OBJECTIVE(S)

To compare antiretroviral resistance susceptibility testing of patient HIV-1 strains using genotype and phenotype methods.

DESIGN

Eighteen plasma samples with viral load > 2000 HIV-1 RNA copies/ml were randomly selected for testing by both methods. Disease and treatment data were available for all patients.

METHODS

Samples were analysed genotypically using a kit assay (HIV-1 Genotyping Systems, Applied Biosystems), performed by the Clinical Research Laboratory at Macfarlane Burnet Centre for Medical Research. Samples were analysed phenotypically using a rapid phenotypic assay (PhenoSenseTM HIV, ViroLogic), performed by the manufacturer. Results from both methods were interpreted using a defined protocol. Each susceptibility assay was performed and interpreted by individuals unaware of either the clinical data or the results of the other susceptibility assay. Concordance was defined categorically as either the presence of reduced susceptibility (> 2.5-fold change) in the phenotypic assay and resistance associated mutations in the genotypic assay, or the absence of these findings in both assays.

RESULTS

Concordance between phenotypic and genotypic susceptibility testing was 81% for nucleoside reverse transcriptase inhibitors, 91% for non-nucleoside reverse transcriptase inhibitors and 90% for protease inhibitors. Complete concordance between phenotype and genotype for all 14 drugs evaluated was observed in three (17%) patient samples.

CONCLUSIONS

Phenotypic and genotypic susceptibility appear to provide similar results. However, interpretation of genotypic results can be complicated, and both methods still require clinical validation.

"Helicobacter rappini" isolates from 2 homosexual men

We report 2 cases of bacteremia due to "Helicobacter rappini" in 2 young, homosexual men, including the first report of H. rappini in a human immunodeficiency virus-positive patient. Blood cultures showed a spiral, fusiform, gram-negative bacterium with bipolar sheathed flagella.

Nocardia infection in heart-lung transplant recipients at Alfred Hospital, Melbourne, Australia, 1989-1998

Nocardia infections are uncommon in recipients of heart, lung, or heart-lung transplants, but such infections are well described. Frequent episodes of rejection, high-dose prednisolone treatment, renal impairment, and prolonged respiratory support have all been shown to increase the risk of Nocardia infection in this group. In this retrospective review of 540 recipients of heart, lung, or heart-lung transplants, 10 patients developed Nocardia infection (frequency, 1.85%). Infection occurred at a mean +/- standard deviation of 13+/-14.5 months after transplantation. All patients had pulmonary disease with no evidence of extrapulmonary disease. The Nocardia infection did not contribute directly to patient deaths. Coinfection with other pathogens was present in 6 patients, and 2 patients had sequential infections. Radiological findings varied. All isolates were susceptible to trimethoprim-sulfamethoxazole, amikacin, and imipenem. Treatment regimens varied. Two (30%) of 6 patients treated with trimethoprim-sulfamethoxazole developed adverse reactions, which necessitated a change in antibiotic therapy. The optimal treatment regimen, which comprises both the antimicrobial agent and the length of treatment, is unclear.

Granulocyte-macrophage colony-stimulating factor augments phagocytosis of Mycobacterium avium complex by human immunodeficiency virus type 1-infected monocytes/macrophages in vitro and in vivo

The role of human immunodeficiency virus type 1 (HIV-1) infection on the ability of human monocytes/macrophages to phagocytose Mycobacterium avium complex (MAC) in vivo and in vitro and the effect of granulocyte-macrophage colony-stimulating factor (GM-CSF) on this function were investigated. By use of a flow cytometric assay to quantify phagocytosis, HIV-1 infection was found to impair the ability of monocyte-derived macrophages to phagocytose MAC in vitro, whereas GM-CSF significantly improved this defect. Phagocytosis was not altered by exposure to a mutant form of GM-CSF (E21R) binding only to the alpha chain of the GM-CSF receptor, suggesting that signaling by GM-CSF that leads to augmentation of phagocytosis is via the beta chain of the receptor. In a patient with AIDS and disseminated multidrug-resistant MAC infection, GM-CSF treatment improved phagocytosis of MAC by peripheral blood monocytes and reduced bacteremia. These results imply that GM-CSF therapy may be useful in restoring antimycobacterial function by human monocytes/macrophages.

The evaluation of depression in inpatients with HIV disease

OBJECTIVES

The aim of this paper is: to compare the utility of four approaches to the diagnosis of depression in patients with human immunodeficiency virus (HIV) disease; to examine the utility of four rating scales to assess the presence and severity of depression; and to devise a set of substitutive criteria that would be appropriate in patients with HIV disease.

METHOD

A group of inpatients was assessed using standard clinical interview. Patients found to have major depression using DSM-III-R (aetiological) criteria were assessed using inclusive, substitutive and exclusive criteria for the diagnosis of depression. Severity was assessed using the Hamilton Depression Rating Scale (HDRS), the Montgomery Asberg Depression Rating Scale (MADRS), the Beck Depression Inventory (BDI), and the Centre for Epidemiological Studies Depression Rating Scale (CES-D). A group of control patients were matched for age and severity of HIV illness.

RESULTS

Seventeen patients met DSM-III-R (aetiological criteria) for major depression. All were male; they had a mean age of 40.6 years and one-third had acquired immune deficiency syndrome (AIDS). Using alternative approaches to the diagnosis of depression, up to five additional 'depressed' patients were identified ('false positives'). All 17 patients meeting the DSM-III-R criteria also met the substitutive and exclusive criteria but only 15 exclusive criteria. Of the 17 controls (not meeting DSM-III-R criteria), two met substitutive, five inclusive and one exclusive criteria for depression. The mean (+/- SD) scores for the patients and controls were significantly different on all four rating scales. Analysis of individual items on the rating scales revealed that a number did not show significant differences between the depressed and nondepressed groups: on the MADRS the items lassitude and inner tension; on the HDRS the three items depicting anxiety symptoms, loss of libido, hypochondriasis, loss of weight, and maintenance of insight; on the BDI a sense of being punished, disappointed in self, being self-critical, a feeling of looking unattractive, fatigue, weight loss, worried about health and loss of libido; on the CES-D I felt just as good as others, hopeful, talk less, people unfriendly and felt people dislike me.

CONCLUSIONS

The aetiological approach used by clinicians familiar with the features of HIV disease, was found to be useful. All four rating scales differentiated equally well between depressed and non-depressed groups.

Specificity of binding of HIV-1 anti-p24 antibodies to CD4+ lymphocytes from HIV-infected subjects

The clinical utility of a flow cytometric assay (FCA) for intracellular HIV p24 antigen was evaluated in a group of HIV-1-infected subjects. A previously described method, p24-FCA (1), was modified to minimize nonspecific staining and to include irrelevant isotype-matched control antibodies. Blood mononuclear cells from 32 HIV-1 seropositive subjects and 14 HIV-1 seronegative controls were examined. In HIV-1 seropositive individuals, the proportion of CD4+ lymphocytes that bound the p24 monoclonal and the isotype control antibodies were not different. The frequency of cells binding p24 antibodies increased with declining CD4 counts and was highest in patients with low CD4+ lymphocyte counts. Although results of p24-FCA do reflect disease progression, the high nonspecific binding of monoclonal antibodies in infected subjects obscures specific p24 binding and precludes its use as an accurate measure of infection within single cells.

Campylobacter jejuni bacteremia in human immunodeficiency virus (HIV)-infected and non-HIV-infected patients: comparison of clinical features and review

Clinical and bacteriologic features and clinical outcomes of culture-confirmed campylobacter bacteremia in 21 patients (including nine human immunodeficiency virus [HIV]-infected subjects and 12 non-HIV-infected subjects) were retrospectively evaluated and compared. This study highlights differences between HIV-infected and non-HIV-infected individuals. Campylobacter jejuni bacteremia in HIV-infected patients was found to often be a severe, debilitating febrile illness requiring multiple and prolonged courses of antibiotic therapy. Extraintestinal features, particularly pulmonary involvement, were often observed. Cellulitis occurred in one patient. By contrast, in non-HIV-infected patients, the illness was generally an acute onset of fever associated with self-limiting enteritis, with fever resolving rapidly with antibiotic treatment. Travel history (42% of cases) appeared to be a common risk factor in the latter group. Two of these patients had cutaneous manifestations, thus suggesting that some strains may be more invasive. This study suggests that campylobacter bacteremia is an important cause of morbidity and mortality in HIV-infected individuals; the overall mortality rate among HIV-infected patients with bacteremia in this study was 33%. This is not the case for immunocompetent patients, in whom death rarely occurs.

Depressive symptoms in patients with HIV infection: a further exploration

OBJECTIVE

The aim of this study was to assess the frequency and severity of depressive symptoms, to determine the rate of depressive disorder, to explore possible reasons for the development of depressive symptoms and to examine the effects of depression in a group of human immunodeficiency virus (HIV)-positive patients.

METHOD

HIV-positive patients attending an outpatient treatment facility were assessed by the research psychologist and completed a number of questionnaires: the Beck Depression Inventory (BDI); the Life Event Inventory (LEI); the Core Bereavement Item (CBI-17) questionnaire; and the Psychosocial Adjustment to illness Scale (PAIS). Patients scoring > or = 14 on the BDI were seen by the psychiatrist for further assessment, and where appropriate, diagnoses were made according to DSM-III-R criteria.

RESULTS

One hundred and ninety-two patients participated in the study; 95 scored > or = 14 on the BDI and one-third of these were found to have a depressive disorder. Factors significantly predictive of a BDI score > or = 14 were: an LEI score > 77; a diagnosis of acquired immunodeficiency syndrome (AIDS); being on sickness benefits or a pension; no current relationship; and a past history of depression. Few differences were demonstrated between those with a depressive disorder and those with a BDI score > or = 14 but no diagnosis of depressive disorder. Both groups had high mean PAIS scores indicating significant illness effects in multiple areas of function.

CONCLUSIONS

Depressive symptoms are common among patients with HIV infection. Few factors differentiate between patients with a depressive disorder and those whose depressive symptoms do not meet diagnostic criteria. Substantial disability is present in both groups.

Liaison psychiatry in an HIV/AIDS unit

OBJECTIVE

To provide an overview of the work of a liaison psychiatry service to an HIV/AIDS inpatient unit, and particularly to examine the identification of mood and related disorders by referring doctors.

METHOD

The MICRO-CARES prospective clinical database system was used to obtain data on all patients referred to the HIV/AIDS consultation-liaison psychiatry service in an infectious diseases hospital in Melbourne.

RESULTS

Three hundred and ninety-two inpatient referrals were made in the 2 years from 1993-1995: a referral rate of 16.7%. The most frequent reasons for referral were evaluation of coping problems (42%), assessment of possible depression (31%), and assessment of psychotropic medication (24.5%). The most common psychiatric diagnoses were mood disorders (36.5%), psychoactive substance use disorders (22.7%) and organic mental disorders (18.1%). Overall concordance of recognition of depression by the referring doctor and diagnosis of depression by the consultant psychiatrist was 79%; 20% false positive rate, 23% false negative rate.

CONCLUSIONS

Psychiatric comorbidity is common in patients with HIV/AIDS. Reasons for referral vary from those seen in other inpatient settings. Previously noted problems such as the misdiagnosis of psychiatric disorder and the mislabelling of the syndrome recognised by psychiatrists as depression were noted here.

Fertility and reproductive choice in women with HIV-1 infection

OBJECTIVE

To measure fertility and birth rates and to describe the reproductive histories of women diagnosed with HIV-1 infection in Australia.

METHODS

The medical records of 294 women with HIV-1 infection in four states of Australia were reviewed. Expected fertility and birth rates were calculated using national statistics.

RESULTS

In the study population, 152 (52%) women had at least one pregnancy prior or subsequent to HIV-1 diagnosis. At maternal HIV-1 diagnosis, 71 (24%) women had a total of 106 children aged under 15 years. During the study period, 246 women were aged 15, 44 years and 58 (23%) of these became pregnant after HIV-1 diagnosis. Women whose exposure to HIV-1 was injecting drug use were twice as likely to become pregnant and more likely to have multiple pregnancies than women who did not report injecting drug use. The annual general fertility rate was 30 per 10,000 compared with 63 per 10,000 for the Australian female population aged 15-44 years, and the birth rate in women with HIV-1 infection was one-half that of the general female population. Of pregnancies confirmed after HIV-1 diagnosis, 47% were voluntarily terminated, a rate more than double that of the general population. All multiple terminations were among women whose exposure to HIV-1 was injecting drug use.

CONCLUSIONS

Fertility and birth rates among women with HIV-1 infection are lower than the general population and the rate of termination higher. The results of this study provide a basis for the management of women with HIV-1 infection who are considering pregnancy.

Helicobacter cinaedi bacteraemia: varied clinical manifestations in three homosexual males

We report 3 cases of Helicobacter cinaedi bacteraemia in different hosts representing a spectrum of clinical illness associated with this infection. The first was an AIDS patient with relapsing H. cinaedi bacteraemia despite antibiotic treatment. The second was an HIV seronegative homosexual man with end-stage renal failure, receiving haemodialysis and a previous history of chronic lymphoedema of his legs. He developed H. cinaedi bacteraemia with cellulitis of his left leg. Patient 3, an HIV seronegative homosexual man, had transient H. cinaedi bacteraemia 2 days after the completion of a course of chemotherapy for bilateral testicular carcinoma. The clinical spectrum of disease associated with H. cinaedi is broad, with few specific clinical features. Successful recovery of this fastidious organism from blood aids in the diagnosis of this unusual infection.

Emergence of multidrug resistance in Campylobacter jejuni isolates from three patients infected with human immunodeficiency virus

Single-drug resistance to tetracycline, doxycycline, erythromycin, or fluoroquinolones in Campylobacter isolates recovered from humans has been documented worldwide. Multidrug resistance to these antibiotics is rare in Campylobacter jejuni. We report the sequential development of multidrug resistance in C. jejuni isolates from three patients who were infected with human immunodeficiency virus. Multiple isolates recovered from stool specimens from these patients were ribotyped, and antibiotic susceptibility profiles were determined. The results indicated that each patient was infected with a single strain of C. jejuni that had progressively acquired resistance to the antibiotics used during treatment. The emergence of resistant isolates appeared to correlate with clinical relapse. In these patients, campylobacter enteritis was prolonged, severe, and relapsing, and antimicrobial therapy was required. Once these first-line antibiotics become ineffective, few other antibiotics are available for treating patients with campylobacter enteritis. Acquisition of antibiotic resistance in C. jejuni is therefore of concern in these cases.

Clinical effects and in vitro studies of trifluorothymidine combined with interferon-alpha for treatment of drug-resistant and -sensitive herpes simplex virus infections

Three AIDS patients with severe cutaneous herpes simplex virus (HSV) infection refractory to therapy with acyclovir and foscarnet (2 patients) were treated with a topical preparation of trifluorothymidine (TFT) and interferon-alpha. Complete healing of lesions occurred in 1 patient; a second had significant regression of the infected area. In the third, the lesion was stabilized twice after application of the preparation and reduced in size after a subsequent treatment. In vitro studies confirmed that isolates from these patients were acyclovir- or acyclovir/foscarnet-resistant. In addition, they revealed strong synergy between TFT and interferon-alpha for these isolates and for strains with wild-type drug sensitivity profiles. Topical TFT/interferon-alpha may be of benefit in the therapy of mucocutaneous HSV infections, especially when they are resistant to treatment with systemic antiviral agents.

Invasive aspergillosis in AIDS

Invasive aspergillosis (IA) is a rare infection in patients with the Acquired Immune Deficiency Syndrome (AIDS). We report the first Australian cases of histologically and microbiologically proven IA diagnosed antemortem in AIDS patients. We also describe the first case of laryngeal involvement and the unusual case of a pneumothorax due to IA. These three cases illustrate the varied clinical and pathological features of IA in AIDS and highlight some of the difficulties in diagnosis and treatment. The infections occurred in the setting of advanced immunodeficiency and multiple opportunistic infections and responded poorly to treatment.

Hypothyroidism due to destruction of the thyroid by Kaposi's sarcoma

A case of hypothyroidism that manifested as depression and deteriorating functional status and that ultimately resulted in the death of a 41-year-old patient with AIDS is described. Postmortem examination revealed destruction of the thyroid gland by Kaposi's sarcoma. Analysis of stored serum samples revealed that the patient had become profoundly hypothyroid during his terminal illness. Practitioners are reminded of the need to exclude metabolic causes when treating encephalopathy in patients infected with human immunodeficiency virus.

The increased risk of fatal liver disease in renal transplant patients who are hepatitis Be antigen and/or HBV DNA positive

To determine whether active viral replication is associated with increased morbidity and mortality in chronic carriers of hepatitis B virus (HBV) undergoing renal transplantation, we reviewed 23 years of experience at our hospital. Over the period 1966-1989, 42 chronic carriers of hepatitis B surface antigen (HBsAg) received renal transplants, 32 of whom had functioning grafts for 12 months or longer. Stored sera were tested for markers of hepatitis B virus, hepatitis C virus (HCV), and hepatitis delta virus (HDV) infection, and the serologic findings were correlated with clinical and biochemical data. The presence of HBV DNA and/or hepatitis Be antigen (HBeAg) in serum samples collected prior to transplantation was associated with an increased probability of death from liver disease. Whereas 5 of 10 patients in this group died of chronic liver disease, only 1 of 15 patients who were HBV DNA and/or HBeAg negative prior to transplantation died of liver disease. This difference is highly significant (P less than 0.02). No difference in outcome was attributable to age at transplantation, gender, country of birth, or the presence of abnormal hepatic transaminase levels prior to transplantation.

Quadruple-drug therapy for Mycobacterium avium-intracellulare bacteremia in AIDS patients

The mycobacterial response was evaluated for patients with Mycobacterium avium-intracellulare complex (MAC) bacteremia treated with a quadruple regimen of rifabutin, clofazimine, isoniazid, and ethambutol. Mycobacteremia was cleared in 22 of 25 patients who received this regimen, and 18 patients experienced complete resolution of symptoms associated with MAC infection. All of the patients were immunodeficient, with a mean CD4 cell count at the time of diagnosis of MAC infection of 54.7 +/- 54.6 cells/microliters. All MAC isolates were resistant to clofazimine, isoniazid, and ethambutol. Sixteen of 24 isolates were resistant to rifabutin. Improved results of treatment may be related to the use of a higher dose of rifabutin (300-600 mg/day) compared with other studies (150-300 mg/day), earlier diagnosis and institution of treatment, and synergy between rifabutin and ethambutol. The quadruple regimen used in this study appears effective in clearing mycobacteremia and in ameliorating symptoms of infection.

Primary dapsone chemoprophylaxis for Pneumocystis carinii pneumonia in immunocompromised patients infected with the human immunodeficiency virus

During a 12-month period from August 1, 1986 to July 31, 1987, a study of primary chemoprophylaxis with dapsone for Pneumocystis carinii pneumonia was undertaken in immunodeficient patients who were infected with the human immunodeficiency virus. One attack of P. carinii pneumonia occurred among 16 patients who received chemoprophylaxis immediately that a T-helper (CD4) lymphocyte count of less than 0.2 x 10(9)/L was recorded compared with 16 attacks in the historical control group of 46 similar patients who did not receive chemoprophylaxis (log-rank test, chi 2(1) = 3.72; P = 0.05).

Hepatitis B and renal transplantation

Renal transplantation in HBsAg+ chronic carriers has a relative low risk of progressive liver disease, with mortality associated with liver disease at 7%. In contrast, HBsAg+ recipients who acquired their disease in the early posttransplant period had a mortality of 60%. HBeAg-positive patients who remain persistently positive are a subgroup with a poor prognosis and should not be offered a renal transplant.

Methyldopa: an often overlooked cause of fever and transient hepatocellular dysfunction

The clinical features and laboratory findings of 78 cases of methyldopa fever are reported. This drug reaction masqueraded as a variety of acute infectious diseases including septicaemia, meningitis, hepatitis and gastroenteritis, occurred within five weeks of starting the drug and appeared to be unrelated to its dosage. Eosinophilia and skin rashes were conspicuous by their absence. In the majority of patients, symptoms were relieved within 48 hours of the withdrawal of the drug. Sixty-one per cent of patients had biochemical evidence of liver damage but jaundice was uncommon. This pattern of mild hepatotoxicity in patients with early febrile reactions to methyldopa contrasts with the later more serious viral hepatitis-like illness due to the drug.

Angioimmunoblastic lymphadenopathy associated with large-muscle arteritis

This is the reported case of angioimmunoblastic lymphadenopathy associated with large-muscle arteritis. Additional features included severe thrombocytopenia, IgG lambda paraproteinemia, and terminal staphylococcal and candidal infections.