Background: Current HIV treatment guidelines recommend antiretroviral treatment (ART) initiation for all HIV-infected individuals regardless of CD4 count. This study evaluates the immunological and virological status and the clinical characteristics of patients who have started ART in the last 8 years in the Northwest of Spain. Methods: All HIV-infected patients who have started ART between January 2009 and December 2016 at a reference hospital in the Northwest of Spain were included in this retrospective observational study. Epidemiological, clinical, and immunovirological features and antiretroviral drugs used for initiation were recorded. A statistical analysis was performed using SPSS version 19 software. Categorical and continuous variables were compared by the specific statistical tests, and a logistic regression model was used to identify time associated with Center for Disease Control and Prevention (CDC) categories change. Results: A high proportion of HIV-infected patients (66.7%) had initiated ART with CD4 counts <350 cells/mm 3 in the last 8 years. From these, most of them (68.3%) had <350 CD4 counts at first contact with HIV specialist medical team, 12.2% had no indications for ART initiation in the last clinic visit before ART initiation according to the national guidelines at that moment, 11.0% were lost to follow-up because of lack of compliance with scheduled visits and 8.5% of patients refused treatment. A logistic regression model showed that a delay of one month since the first contact with HIV specialist medical team to ART initiation involves a risk of worsening in the CDC clinical category (odds ratio: 1.02 [95% confidence interval: 1.012-1.029]; P < .001). A trend towards an earlier start of ART was observed during 2015 and 2016, likely influenced by the last treatment guidelines recommendations. Conclusion: High proportion of HIV-infected patients (66.7%) had initiated ART with CD4 counts <350 cells/mm 3 in the last 8 years. The main reasons for this problem were analyzed and an important rate of late diagnosis was identified. However, a trend towards an earlier start of ART was observed during 2015 and 2016, likely influenced by the last treatment guidelines recommendations. These findings highlight the need to promote and facilitate HIV testing to reduce the late diagnosis as well as counseling on HIV prevention, treatment, and linkage care.
HIV-associated cryptococcal meningitis (CM) is estimated to cause over half a million deaths annually in Africa. Many of these deaths are preventable. Screening patients for subclinical cryptococcal infection at the time of entry into antiretroviral therapy programs using cryptococcal antigen (CRAG) immunoassays is highly effective in identifying patients at risk of developing CM, allowing these patients to then be targeted with “preemptive” therapy to prevent the development of severe disease. Such CRAG screening programs are currently being implemented in a number of countries; however, a strong evidence base and clear guidance on how to manage patients with subclinical cryptococcal infection identified by screening are lacking. We review the available evidence and propose a treatment algorithm for the management of patients with asymptomatic cryptococcal antigenemia.
Efavirenz (EFV) is primarily metabolized by cytochrome P450 (CYP) 2B6 and to a lesser extent by CYP3A4. Drugs that significantly inhibit or induce these enzymes would then be expected to increase or lower the levels of EFV potentially resulting in toxicity or therapeutic failure, respectively. The constituents of Ginkgo biloba extract have been demonstrated to induce gene expression of the CYP450 enzymes. We report a case in which a potential drug–herb interaction may have led to virological breakthrough in a patient that was maintained on the same regimen for 10 years. Therefore, a drug–herbal interaction may be expected when these agents are taken concurrently, and we advise clinicians to avoid this combination when possible. Keywords HIV , antiretroviral , efavirenz , , , , drug interaction
Although the identification of individuals infected with HIV is an important element of treatment and prevention programs, many people living with HIV are unaware of their status. Thus, individuals are unable to benefit from treatment, and preventable HIV transmission continues to occur. Rapid point-of-care testing for HIV has been found to be preferred by patients in some contexts. However, few studies have examined preferences in primary care populations. This study investigates HIV testing preferences within an urban primary care clinic. Employing a cross-sectional design, data were collected on demographic characteristics, HIV risk factors, and testing history and preferences of participants. A total of 81% of participants stated that they would prefer rapid testing to standard testing, a finding that is consistent across demographic variables and risk factors examined. Increased availability of this modality may decrease barriers to HIV testing, with positive implications both for clinical management of HIV infection and prevention of HIV transmission.
Background: Little is known about patients' health literacy regarding antiretroviral therapy (ART) adherence and drug resistance and patient–provider communication about these topics. Design and Methods: The AIDS Treatment for Life International Survey was a multicountry cross-sectional study (January-March 2010) including 2035 HIV-infected adults. A 40-minute interview was conducted using a standardized self-report adherence questionnaire. Results: Overall, 57% of patients reported a 30-day recall of 100% adherence (Latin America: 89%; Africa: 73% vs North America: 45% and Asia Pacific: 47%; P < .01). Overall, 18% identified HIV drug resistance as a “good thing” in North America (35%) and Africa (24%). Only 71% said their health care providers had offered practical recommendations about adherence, 62% of the patients in North America and 80% in Latin America and Africa. Conclusions: Optimal ART adherence remains a challenge globally. There is a critical need to improve patient–provider communication about the importance of ART adherence and its benefits for patient’s health.
INTRODUCTION:I-TECH India established a warmline pilot in the year 2008 to provide mobile-based technical support on clinical management to doctors caring for HIV patients in antiretroviral therapy (ART) centers.METHODS:Warmline was piloted from May to August 2008. Standardized call records were analyzed. Statistical analyses were performed using SPSS.RESULTS:The service was used by 38 doctors. The study demonstrated the frequency of calls and the nature of questions raised by them. Of the calls, 139 were new calls (90.3%) and 15 were follow-up calls. The average number of calls per day was 2.6 (SD 1.6). Of the total number, 81% of the calls were from high-volume centers. Most of the calls were related to ARV toxicities, ART initiation, and the management of opportunistic infections (OI).CONCLUSION:The South Indian warmline pilot demonstrated a potential model of ongoing technical assistance to ART doctors in times of need. AIDS-control organizations may consider expanding this model of expert distance-mentoring clinical support as a resource in India and other countries.
Vitamin D plays role in bone health and the regulation of the immune system. A cross-sectional study of serum 25-hydroxyvitamin D (25[OH]D) levels was conducted among HIV-1-infected Thai patients to determine the prevalence and associated factors of low vitamin D levels (25[OH]D <30 ng/mL) in tropical setting. 25-Hydroxyvitamin D was measured by liquid chromatography/tandem mass spectrometry. Of 178 patients, 58% received antiretroviral therapy at median (interquartile range [IQR]) duration of 7.4 (5.9-8.5) years. The prevalence of 25(OH)D deficiency (<20 ng/mL) and insufficiency (20-29.9 ng/mL) was 26.8% and 44.9%, respectively. Multivariate analysis showed that receiving efavirenz (EFV) was significantly associated with low vitamin D status (odds ratio = 3.60; 95% confidence interval, 1.06-12.15, P <.05). The mean (±standard deviation) level of 25(OH)D in patients receiving and not receiving EFV was 22.9 (6.6) and 28.6 (10.7) ng/mL, respectively, (P <.05). Low vitamin D status is common and needs to be assessed among HIV-infected patients including tropical residents especially when EFV is used.
HIV infection changed the scenario of infectious diseases. The pre-HAART (highly active antiretroviral therapy) era had resulted in new opportunistic infections. HIV and tuberculosis together had high mortality in countries with high prevalence of tuberculosis. Disseminated and extra pulmonary tuberculosis is common in PLHA (People Living with HIV and AIDS). IRIS (Immune Reconstitution Inflammatory Syndrome) after HAART is common (10% to 25%) in PLHA. Pott's spine is the most common presentation in PLHA of bone and skeletal system. IRIS tuberculosis, especially extra pulmonary tuberculosis, is the most common. In this case, we are presenting an IRIS disseminated tuberculosis in the form of acute osteomyelitis and mutilating dactylitis involving many joints of the fingers. Of 37 cases (9 from India) reported worldwide multiple dactylitis was never presented in the medical journals. This might be the first multiple dactylitis with extensive mutilation to the dactyls due to IRIS in a patient on ART.
Nevirapine (NVP) was the first nonnucleoside reverse transcriptase inhibitor (NNRTI) approved by the US Food and Drug Administration (FDA) in 1996, for the treatment of HIV infection. Current treatment guidelines include NVP as a component of a recommended alternative NNRTI regimen, which may be the preferred regimen for patients with established cardiovascular risk factors since NVP has minimal untoward effects on serum lipids. Two randomized and controlled clinical trials established the noninferior virologic efficacy of twice-daily NVP versus ritonavir-boosted atazanavir (ATV/r), a protease inhibitor with limited effects on serum lipids, each drug on a background regimen of once-daily (QD) tenofovir (TDF)/emtricitabine (FTC). An extended-release (XR) formulation of NVP was developed since QD dosing and reduced pill burdens have been shown to improve regimen adherence. This formulation (Viramune XR 400 mg) was recently FDA approved based on the results of 2 randomized, controlled clinical trials. The XR formulation will provide additional treatment options for patients who may benefit from NVP-based regimens.
Viral hepatitis is a disease of great concern to public health that is now met by a favorable momentum to combat the global epidemic. This article is intended to highlight the importance of viral hepatitis in the Vietnam population as well in the group of people living with HIV/AIDS (PLWHA). We reviewed available data on epidemiology and response on hepatitis B virus (HBV) and hepatitis C virus (HCV) and HIV coinfection in Vietnam. The hepatitis B surface antigen (HBsAg) prevalence in the general population ranged from 5.7% to 24.7%. The anti-HCV prevalence ranged from 0.38% to 4.3% in the general population, while among people who inject drugs (PWIDs) it ranged from 31% to 97.2%. The HBV prevalence among PLWHA is similar to the general population, while HCV/HIV coinfection is concentrated in some groups. Anti-HCV prevalence among HIV-infected PWIDs can be as high as 98.5%. Developing policies for diagnosis and treatment of chronic HBV and HCV infections are critical priorities in order to prevent clinical progression to cirrhosis and liver cancer.
Dr Shuter et al reported the results of a study examining the stability of the adherence to antiretroviral therapy (ART) measured by Medication Event Monitoring System (MEMS) in 2 separate time points. It is very interesting to discern the extent that short-term adherence measured by MEMS technology predicts the adherence to antiretroviral (ARV) medications over the long run. Adherence to ART is the mainstay of HIV treatment since excellent adherence is associated with favorable viral suppression. Clinical trials and longitudinal studies usually provide the capacity to assess the adherence to ART over a short period of time (typically 24-week measurements); however, it is the long-run adherence that identifies the adequacy of treatment to achieve the desirable viral suppression and HIV clinical outcomes. For this purpose, the authors compared the adherence measured by MEMS cap monitoring among a cohort of HIV-infected patients that participated in a study in 2004 to 2005 (study I) and the same cohort recruited again between 2008 and 2009 (study II) to repeat measuring ART adherence after 4 years. The authors showed that the mean adherence rates in the first and second periods were not significantly different and are, in fact, strongly correlated. They conclude that the ART adherence rates measured by MEMS caps are closely correlated at 2 time points several years apart. The findings of this study are remarkable; however, there are a few issues that need to be considered before drawing any inference. First, seemingly patients with more favorable adherence to ARV medications and/or less-advanced HIV disease are more likely to be included in the study cohort. In study I, 84 patients were primarily enrolled and 64 completed the study. The characteristics of participant and nonparticipants were assessed. Participants had a higher CD4 count compared with those who did not participate. In study II (2008-2009), of 64 participants who completed study I, authors included in the final analysis only 48 participants who managed to complete study II, whereas 16 (25%) were excluded (4 had died, 8 had been lost to follow-up [hence not recruited for study II], and 4 did not complete study II). The mean adherence rate in study I of the 16 participants who did not complete study II was not significantly different from the 48 participants who were included in the analysis. Nevertheless, it is not unlikely to contemplate that these individuals’ adherence and behaviors have changed over time from their initial adherence profile in study I. This potential change in adherence in turn can explicate, at least in part, their outcomes being mortality, loss to follow-up, or dropout. In addition, the proportion of patients meeting the criteria to be diagnosed with AIDS was 80% in the first period, while this proportion decreased to 75% in the second cohort. This is despite the fact that provided the ‘‘time elapsed since HIV diagnosis’’ was relatively high in the beginning of study I, it is not unreasonable to expect more, rather than less, AIDS cases after 4 more years. Exclusion of individuals with more advanced HIV disease and/or with less favorable adherence to ART might have had the sample in the second period mostly comprising ‘‘survivor’’ cases. Notably, there is a trend of decrease in adherence rate from study I to study II (74.2% vs 68.9%; P 1⁄4 .09), however, the proportion of virally suppressed patients (viral load <75 copies/mL) increased significantly from study I to study II (60.4% vs 79.2%; P 1⁄4 .05), which supports the abovementioned observation. Second, 12 of 48 cases included in study II had switched to new drug regimens. The adherence rate of periods I and II were found to be significantly correlated among those who remained on their initial regimen (N 1⁄4 36), whereas there was no significant correlation among those who switched to a new drug regimen (N 1⁄4 12). New regimens are usually prescribed to those who do not achieve favorable outcomes with their initial regimen (in fact, 8 of 12 had detectable viral loads preceding switching to new regimens). These regimens confer less daily dosing frequency and hence confer the potential of increased adherence. In summary, exclusion of some cases from the sample might have introduced biases, overestimated the adherence rate in the second study, and restrained its generalizability. Also, more robust statistical approaches besides correlation and quartile stratification may be employed to ascertain the agreement between the absolute adherence rates of 2 measurements.
Distance learning is an important tool for training HIV health workers. However, there is limited evidence on design and evaluation of distance learning HIV curricula and tools. We therefore designed, implemented, and evaluated a distance learning course on HIV management for clinical care providers in India. After course completion, participant scores rose significantly from a pretest (78.4% mean correct) compared with the posttest (87.5%, P < .001). After course completion, participants were more likely to be confident in starting an initial antiretroviral (ARV) regimen, understanding ARV toxicities, encouraging patient adherence, diagnosing immune reconstitution syndrome, and monitoring patients on ARV medications ( P ≤ .05). All participants (100%) strongly agreed/agreed that they would recommend this course to others, and most of them (96%) strongly agreed/agreed that they would take a course in this format again. A pragmatic approach to HIV curriculum development and evaluation resulted in reliable learning outcomes, as well as learner satisfaction and improvement in knowledge.
This study was conducted to assess the prevalence of depressive symptoms, sleep disturbances, and subjective cognitive complaints in patients with HIV receiving highly active antiretroviral therapy. Participants completed the "Center for Epidemiological Studies Depression Scale" (CES-D) and a questionnaire on sleep disturbances and subjective cognitive complaints. Mean age of the 799 participants was 43.7 years and 67% were men. Adjusted prevalence of CES-D was 35.4% (95% confidence interval [CI]: 32.0-38.7), with no significant differences between gender and age groups. Sleep disturbances were more prevalent in older versus younger participants (74.0% [95% CI: 70.4-77.7] versus 63.3% [95% CI: 56.8-69.8]). Cognitive complaints were more prevalent in women (52.3% [95% CI: 46.4-58.2]) when compared with men (48.2% [95% CI: 44.7-51.6]). Hepatitis C virus coinfection was a strong predictor of depressive symptoms. Male gender and detectable viral load were independent risk factors for sleep disturbance. A higher CES-D score was an independent risk factor for sleep disturbance and cognitive complaints.
Background: Most studies examine health care provider definitions of cultural competence practice. However, this study explores the impact of African Americans’ perception of HIV health care provider cultural competence on adherence to self-care and antiretroviral (ARV) medication. Methods: The study was conducted at the CORE Center in Chicago, Illinois. The sample consisted of 202 African-American adults with HIV/AIDS who were recruited from clinic waiting areas. Surveys were self-administered, and participants received a $10 food gift card as an incentive. Cultural competence was measured using the Patient Assessments of Cultural Competency (PACC) survey developed by the Department of Health and Human Services Agency for Healthcare Research and Quality (AHRQ). Medical self-care was measured using 2 scales, and ARV medication adherence was measured using scales published by the Adult AIDS Clinical Trials Group. Data were analyzed using descriptive statistics, Pearson r correlation coefficients, and linear regression. Data were examined after controlling by covariates. Results: There was a significant relationship between health care provider trust with communication (r 1⁄4 0.41, p 1⁄4 .0001) and adherence to health care provider advice (r 1⁄4 0.40, p 1⁄4 .0001). The less health care providers shared treatment decisions with patients, the less patients adhered to ARV medication (r 1⁄4 0.45, p 1⁄4 .05). Regression results revealed that the more adherent patients were to health care provider advice and instructions, the more culture was important, F(1, 138), 1⁄4 0.029, p 1⁄4 .05. Participants with higher degrees, F(1, 138), 1⁄4 0.136, p 1⁄4 .05, perceived that patient culture was less important in HIV care. The more patients trusted their providers, the more they engaged in medical self-care, F(1, 138), 1⁄4 0.280, p 1⁄4.01. Patients were less trustful of nurses, F(1, 138), 1⁄4 5.559, p 1⁄4.01. Conclusions: Practice, research, and policy implications were discussed.
BACKGROUND:Little is known globally about the perspectives of people living with HIV/AIDS (PLWHA) on perceived HIV-related stigma and its consequences.METHODS:Cross-sectional study (January-March 2010) of perceived HIV-related stigma among PLWHA (N = 2035) using a standardized questionnaire.FINDINGS:Thirty-seven percent of respondents reported loneliness as a result of their HIV status. Depression was reported by 27%. While 96% reported disclosing their HIV status to at least 1 person, 17% of patients who reported being in a long-term sexual relationship had not disclosed their status to their partner. Variables associated with perceived stigma were living in Asia-Pacific versus other regions (odds ratio [OR]: 2.77; 95% confidence interval [CI] 1.96-3.92); having experienced body/face changes; reported depression (OR: 1.25; 95% CI 1.11-1.38); and nondisclosure of HIV status (OR: 1.75; 95% CI 1.28-2.41).CONCLUSION:Thirty years into the HIV pandemic, perceived HIV stigma, isolation, and discrimination persist and are associated with loneliness and depression among PLWHA.
Multiple studies have demonstrated increased rates of osteopenia and osteoporosis in HIV-infected patients but there have been no published studies on current screening practices. We conducted a retrospective chart review of 2924 patients attending an urban HIV clinic. Thirty patients (1%) had dual-energy x-ray absorptiometry (DXA) scans. Patients undergoing DXA scans were more likely to be older, women, and have nondetectable HIV viral load and CD4 count ≥200. The most frequently cited indications for screening were perimenopausal or postmenopausal status and HIV infection. Of the patients screened, 96% had osteopenia or osteoporosis with a median T-score of −1.9 and a median of 3.8 osteoporosis risk factors in addition to HIV. Of the 20 practitioners in the clinic, only 7 had patients with screening DXA scans. DXA scans are underutilized in the HIV population given the high rate of osteopenia and osteoporosis detected in this study.
OBJECTIVE:Our objective was to determine attitudes and opinions of patients seen in our ID Unit on conducting HIV testing universally.METHODS:The survey was conducted in patients between 18 and 65 years without known HIV infection. Requested information about the test was previous embodiment, reasons for rejection, opinion on the universal realization, benefits and/or drawbacks, possible test performance, and availability of results "test negative stigma."RESULTS:We surveyed 91 patients (54.9% males). Surprisingly, up to 18.7% of patients mistakenly believed that HIV testing is routinely performed without consent. A great majority (98.9%) felt that universal performance on the test would benefit mainly in early diagnosing and/or preventing transmission. Patients younger than 42 years were significantly more prone to doing the test as a routine procedure. Only 4 (4.4%) patients did not participate because they believed they were "not infected." A vast majority (80.5%) of respondents would prefer to have results within the first 24 hours. In addition, 20.7% would have a problem with confidentiality if HIV serology testing was done.CONCLUSIONS:In summary, the vast majority (95.6%) of the surveyed patients had a fair opinion about universal HIV testing. Only 4 patients (4.4%) would not consent to HIV testing (because of low-risk perception). Availability of rapid HIV tests can facilitate fast result delivery, facilitating linkage to care. Considering favorable patients' opinion, recent opt-out screening recommendations, highest HIV prevalence in admitted patients, and cost-effectiveness, studies favor universal HIV testing.
Liver disease is very common in patients with HIV infection. The association between chronic infection with hepatotropic viruses and being a target for other diseases, such as opportunistic infections and tumors, nonalcoholic fatty liver disease (NAFLD), and toxicity to drugs, including antiretroviral therapy (ART), results in liver disease being a leading cause of morbidity and mortality in these persons. The aim of this study was to determine the prevalence of chronic hypertransaminasemia (CHT) in a cohort of patients with HIV infection but no coinfection and to examine the factors associated with CHT. We undertook a cross-sectional, case-control study of all HIV-infected patients who regularly attended the infectious diseases office of our center from March to August 2009. A case was defined as any patient with glutamate pyruvate transaminase (GPT) values above normal (78 IU/L) at least 2 consecutive revisions (3 months or more between the 2 measurements). Patients were excluded if they had a positive serology to a hepatotropic virus or opportunistic events during the previous month. A control was defined as a patient attending the office paired for age (+5 years) and sex with a case and who had a normal GPT value, using the same exclusion criteria as for the cases. Hepatotoxicity of ART was defined as CHT due to ART, and to make this diagnosis, other causes of elevated GPT values were ruled out in all cases and NAFLD by the presence of steatosis in an abdominal ultrasound in patients consuming <50 g/d of alcohol. The statistical analysis was done with SPSS 17.0 (SPSS, Chicago, Illinois). During the study period, 861 patients attended the office, of whom 454 (52.7%) had a negative serology for hepatotropic virus. Of these, 31 met the inclusion criteria, giving a prevalence of CHT of 6.8%. Most were men, the mean age was 45.7 years, and the predominant mode of transmission of the HIV infection was sexual. In all cases except 1, the elevation of the GPT was mild (<3 times the normal values). The only parameter that differed between cases and controls was a greater body mass index in the cases. Table 1 shows the characteristics of the cases and controls. There were no differences in the use of ART. At least 1 other drug was being taken by 61.2% of the 31 cases and 48.3% of the controls. Lipidlowering drugs were being taken by more of the cases than the controls (15 versus 7, P < .05). An abdominal ultrasound was performed in 11 patients, 9 of whom showed signs of hepatic steatosis. No case had signs of portal hypertension. Liver stiffness could be assessed by elastometry (FibroScan) in 20. The mean stiffness was 5.9 Kps, with a range of 3.3 to 8.8 kPa. No patient had a liver biopsy. The most usual clinical diagnosis attributable to the CHT was ART toxicity, followed by NAFLD. Three patients were convalescing from hepatitis A virus (HAV) infection and 1 from secondary syphilis. Three patients required withdrawal of ART because of the CHT (Table 1). The prevalence of CHT in our series was much lower than the previously reported 11% to 15% values. The prevalence of CHT in a large Swiss cohort was 13.2%, and it was associated with alcohol consumption, NAFLD, and the use of ART. The same study found the incidence to be 3.9 cases per 100 person-years. These differences are probably due to the methods used, the study population, and the differences at the time of the study. Of note, although, is the scarce clinical importance, with just 1 case of moderate CHT and few patients having to cease ART. On the other hand, although only just over one third of our patients had an ultrasound study, NAFLD can currently be considered one of the main causes of CHT in HIV-infected patients with no coinfection. Hepatic steatosis is very usual in the general population, with very large
