A clinical and epidemiological study of an epidemic of viral hepatitis in Azamgarh district of Uttar Pradesh was carried out. A total of 152 patients were examined clinically, and blood and stool samples were collected from patients at different stages of illness, and also from contacts. The study revealed that the epidemic started in July, 1979 and continued till March, 1980. Adults above 15 yr of age were commonly affected. General mortality was 12 per cent with a higher rate in females (20 %) than in males (8.4 %). Pre-icteric phase was severe and prolonged, extending for a week within the icteric phase. HBsAg was positive only in 3.3 per cent. Anti-HAV (IgG) was positive in 95 per cent. IgM anti-HAV was negative in all the 46 samples tested. IgG levels were elevated but IgM and IgA levels were normal. Ten stool samples were examined for virus A particles and all were negative. It is suggested that this epidemic was due to non-A non-B virus as HBsAg and IgM anti-HAV were both negative, and stools In the pre-icteric phase did not reveal the presence of virus A particles.

A consecutive group of 169 patients with acute hepatitis found negative for hepatitis B surface antigen (HBsAg) and negative for IgM antibody against hepatitis A (anti-HAV IgM) was studied for presence of IgM antibody against hepatitis B core antigen (anti-HBc IgM) by ELISA. Anti-HBc IgM was found in a total of 34 of 60 patients with detectable total anti-HBc. One hundred and nine patients had no detectable anti-HBc IgM and no total anti-HBc and were thus considered as having acute non-A, non-B hepatitis. Among the 34 patients with anti-HBc IgM in their first serum sample, 23 were anti-HBs negative and all had high and steadily decreasing ratio unit (RU) values for anti-HBc IgM (mean RU value 17.1). Twelve of the 23 patients showed seroconversion to anti-HBs during the follow-up, indicating an actual hepatitis B virus infection. Eleven of the 34 anti-HBc IgM positive patients had anti-HBs in their first serum sample. In this group, the RU values for anti-HBc IgM were high and steadily declining and the initial values were significantly lower (mean RU value 9.9) (p less than 0.05) than in the anti-HBs negative group. Evidence is provided that anti-HBc IgM in serum from patients with HBsAg negative hepatitis with or without anti-HBs indicates an actual hepatitis B virus infection. According to generally accepted criteria, the demonstration of anti-HBc IgM identified 20% of the 169 patients with acute non-A, non-B hepatitis as having an actual hepatitis B infection.

Objectives: To assess the effect of human immunodeficiency virus (HIV)-1 and syphilis coinfection on HIV-ribonucleic acid (RNA) viral load, CD4 cell count, and the response in rapid plasmin reagin (RPR) to treatment of the syphilis infection. Study Design: Cases of syphilis diagnosed during 1 year in HIV-infected patients in Copenhagen were included. HIV-RNA, CD4 cell counts, and RPR-serology were measured before, during, and after syphilis. Results: Forty-one patients were included. CD4 cell count decreased significantly during infection in patients with primary and secondary stages of syphilis (mean 106 cells/mm3, P = 0.03). Treatment of syphilis was associated with an increase in the CD4 cell count and a decrease in HIV-RNA in the overall group (mean 66 cells/mm3 and −0.261 RNA log10 copies/ml, P = 0.02 and 0.04). The serological response rates for 15 patients treated with penicillin and 25 treated with doxycycline were the same. Conclusion: Syphilis was associated with a decrease in CD4 cell counts and an increase in HIV-RNA levels that both improved after treatment of syphilis.

ObjectivesTo evaluate the long-term pharmacokinetics and safety of adding ritonavir 100 mg twice-daily to a nelfinavir 1250 mg twice-daily regimen in HIV-infected patients.MethodsThis was a prospective, randomized, open-label, controlled 24-week study. Sixteen patients receiving a nelfinavir 12 50 mg twice-daily regimen with plasma viral load < 1000 HIV-1 RNA copies/mL were randomized to continue treatment or to have ritonavir 100 mg twice-daily added. Safety, including fasting lipid levels, was evaluated at weeks 4, 12 and 24. Patients who were randomized to have ritonavir added (n = 9) participated in three 12-h pharmacokinetic evaluations at baseline, week 4 and week 24.ResultsIncreases in median nelfinavir steady-state plasma concentrations at 12 h (Cl 2) from 512 to 773 ng/ mL [median difference 450 ng/mL; 9 5% confidence interval (CI) 116-15 10 ng/mL] and in median active nelfinavir metabolite M8 C-12 from 107 to 603 ng/mL (median difference 545 ng/mL; 9 5% CI 370-891) were seen after the addition of low-dose ritonavir (baseline to week 24). There were no differences between the nelfinavir or M8 pharmacokinetic parameters at weeks 4 and 24. No significant changes or differences in the concentration of fasting total cholesterol, low-density lipoprotein (LDL) cholesterol or total triglycerides or in the occurrence of adverse events were observed within or between the two groups.ConclusionsNelfinavir and especially M8 concentrations are increased when low-dose ritonavir is added to a nelfinavir-containing regimen. The combination seems to be safe and the nelfinavir/ritonavir regimen could be an option in patients with low nelfinavir + M8 concentrations.

Objectives: To investigate the interplay between resistance and adherence in the virological failure of three fundamentally different highly active antiretroviral therapy (HAART) regimens.Methods: We retrospectively identified 56 verified primary virological failures (viral load > 400 HIV-1 RNA copies/mL) among 293 patients randomized to two nucleoside reverse transcriptase inhibitors (NRTIs) + ritonavir + saquinavir (RS-arm) (n = 115), two NRTIs + nevirapine + nelfinavir (NN-arm) (n = 118), or abacavir + stavudine + didanosine (ASD-arm) (n = 60) followed up for a median of 90 weeks. Data on adherence were collected from patient files, and genotyping was performed on plasma samples collected at time of failure.Results: Treatment interruption or poor adherence was mainly caused by side effects and accounted for 74% of failures, and was associated with absence of resistance mutations. In the 30 failing patients not switched from randomized treatment, we found resistance in two of 12 patients in the RS-arm (M184V only), four of six patients in the NN-arm [all four had non-nucleoside reverse transcriptase inhibitor (NNRTI) mutations], and seven of 12 patients in the ASD-arm (NRTI mutations only). Two adherent patients on randomized treatment failed in the RS-arm, none in the NN-arm, and six in the ASD-arm.Conclusions: Primary virological failure was caused mainly by treatment interruption. No primary protease inhibitor (PI) mutations were found in patients failing on boosted saquinavir, whereas resistance to NNRTIs and NRTIs was prevalent in several patients failing on regimens based on these medications.

The aim of this study was to monitor the prevalence of drug resistance mutations in newly diagnosed HIV-1 positive individuals in Denmark. In addition we assessed the prevalence of non-B subtypes based on phylogenetic analysis of the pol gene. Plasma samples from 104 newly diagnosed HIV-1 positive patients were obtained in the year 2000. The entire protease gene and 320 amino acids of the reverse transcriptase gene were genotyped. Sequences were obtained from 97 patients. No subjects displayed primary resistance mutations in the protease gene, whereas all carried 1 or more secondary mutations. Resistance mutations in the RT-gene associated with NRTI-resistance were found in 1 patient, who was infected with zidovudine resistant HIV-1 harbouring the M41L mutation in combination with T215S and L210S. The T215S mutation has been showed to be associated with reversion of zidovudine resistance. The T215S mutation was found in 1 additional patient. The subtype distribution was subtype B 59%, C 18%, A 8%, CRF02_AG 5%, CRF01_AE 4%, D 3% and G 2%. We found 2 patients (2%) with mutations associated with resistance in the RT-gene and none in the protease gene indicating a low prevalence of resistant HIV-1 in Denmark in the year 2000.

Background A triple-class HAART regimen may be associated with a better virological effect than conventional regimens, but may also lead to toxicity and more profound resistance. Methods Randomized, controlled, open-label trial of 233 protease inhibitor- and non-nucleoside reverse transcriptase inhibitor-naive HIV-infected patients allocated to a regimen of nelfinavir and nevirapine (1250/200 mg twice daily; n=118) or ritonavir and saquinavir (400/400 mg twice daily; n=115), both in combination with two nucleoside reverse transcriptase inhibitors. The primary end-point was HIV RNA ≤20 copies/ml after 48 weeks (missing value=failure). Patients remained under follow-up also in case of switch from the randomized therapy. Results At baseline, the median CD4 cell counts were 126 (range: 0–942) (nelfinavir/nevirapine) and 150 (0–642) (ritonavir/saquinavir) cells/mm3, and HIV RNA measurements 5.0 copies/ml (1.3–6.4) in both groups. A total of 102 (86%) and 101 (88%) were antiretroviral-naive. Within 48 weeks, 35 and 44% discontinued randomized therapy; P=0.13. Of these, 80 and 73% switched therapy due to adverse events; P=0.99. At week 48, 69 and 56%, respectively, had a HIV RNA ≤20 copies/ml; P=0.037. Conclusion A regimen of nelfinavir/nevirapine had a favourable virological effect and tolerability over a 48-week period compared with ritonavir/saquinavir, when administered in combination with two nucleoside reverse transcriptase inhibitors. However, more extensive follow-up is required to determine the long-term consequences of triple class HAART regimens, including the development of broad drug resistance.

Objective To study the development of resistance during 8 weeks of salvage therapy with abacavir and nevirapine in combination with other reverse transcriptase inhibitors (RTIs) and protease inhibitors (PIs). Methods Samples obtained at baseline and after 8 weeks of therapy from 16 heavily pretreated patients were analysed for genotypic and phenotypic resistance. Genotypic resistance was analysed in cell-associated DNA and plasma HIV-RNA using direct sequencing. Phenotypic resistance was analysed in a PBMC-based assay and in a recombinant virus assay. Plasma viral load was measured at baseline and after 2, 4 and 8 weeks of therapy. Results The majority of patients was genotypically and phenotypically resistant to lamivudine, abacavir, zidovudine and PIs, whereas 50% of the patients showed resistance to nevirapine at baseline in at least one of the methods used. After 8 weeks of salvage therapy, no additional development of resistance against nucleoside reverse transcriptase inhibitors and PIs could be detected. However, the amount of patients resistant to nevirapine increased to 83%. When the patients were divided into two groups according to baseline resistance against nevirapine, a significantly higher transient reduction in viral load was observed in patients with nevirapine-sensitive HIV at baseline compared to patients with resistant HIV at baseline. Conclusions The transient effect of salvage therapy including abacavir and nevirapine was due to the effect of nevirapine. The lack of effect of abacavir was most likely due to cross-resistance between abacavir and lamivudine/zidovudine used in previous treatment.

The Danish Protease Inhibitor (PI) Study has enrolled 318 human immunodeficiency virus (HIV)-infected, PI-naive patients for the purpose of comparing 3 PI-containing regimens for the treatment of HIV infection. The regimens include 2 nucleoside analogues in combination with indinavir (Idr), ritonavir (Rtv), or Rtv and saquinavir (Rtv/Sqv). Similar percentages of patients in the 3 study arms achieved reduced levels (</=20 copies/mL) of HIV RNA. In the area under the curve minus baseline analyses, a better response was found in the Rtv/Sqv arm than in the Rtv arm. No difference was found when comparing Rtv/Sqv with Idr and Rtv with Idr. Patients in the 3 arms had comparable increases in CD4 cell counts. At 72 weeks of follow-up, there was no statistical difference between arms for the primary study end point (</=20 HIV RNA copies/mL); however, some of the additional analyses indicated an advantage for the Rtv/Sqv arm, especially when compared with the Rtv arm.

Objective To study the association between the Lys to Arg mutation at codon 70 of the reverse transcriptase (RT) gene and resistance development during zidovudine monotherapy and alternating zidovudine/didanosine therapy. Methods Blood samples from 33 antiretroviral-naive patients were drawn prior to therapy and after 6, 12, 18 and 24 months (18 patients received zidovudine monotherapy and 15 patients alternating zidovudine/didanosine). Results: After 6 months of zidovudine monotherapy, 72% of the patients had provirus encoding Lys to Arg at codon 70. This decreased to 53% and 38% after 12 and 18 months, respectively, but increased to 60% after 24 months. During alternating zidovudine/didanosine therapy, the percentages with the mutation were 6%, 7%, 11% and 20% after 6, 12, 18 and 24 months of therapy, respectively. During both therapy regimens provirus showed the same progression of mutations in RT codons 41 and 215, increasing from 10% after 6 months to 80–100% after 24 months. Codon 70 and 215 mutations together were only found with the codon 67 mutation. No significant difference in IC 50 or viral load was shown between patients on either therapy. Conclusions The codon 70 mutation was present in a low proportion of the patients during alternating zidovudine/didanosine therapy compared with patients on zidovudine monotherapy ( P<0.01). Mutations associated with zidovudine resistance appeared in an ordered manner. Based on the phenotypic susceptibility of the virus isolated, the appearance of the different combinations of mutations could be explained by outgrowth of virus with an increased level of phenotypic resistance.

Bronchoalveolar lavage (BAL) fluids and serum samples from 153 patients with pulmonary symptoms who were infected with human immunodeficiency virus (HIV) and underwent BAL were examined for the presence of cytomegalovirus (CMV) by conventional culture and by polymerase chain reaction (PCR) for detection of CMV DNA. PCR detected CMV more frequently than did cultures of BAL fluid (PCR of BAL fluid, 53%; PCR of serum, 40%; and culture, 30%). In a multivariate model, development of extrapulmonary CMV disease was predicted by the finding of CMV in BAL fluid by culture (relative risk [RR], 8.0; confidence interval [CI], 3.8-16.8) or the finding of CMV DNA in serum (RR, 7.4; CI, 3.2-17.3) or BAL fluid (RR, 8.0; CI, 3.1-20.7) by PCR. Mortality was found to be similar for patients who did or did not have CMV detected by either culture or PCR. Detection of CMV DNA by PCR was a more rapid and sensitive technique than conventional culture. Detection of CMV DNA in BAL fluid or serum predicted subsequent development of extrapulmonary CMV disease but not death for HIV-infected patients with pulmonary symptoms.

The aim of this study was to analyse the interplay between the treatment responses, as assessed by serum HIV-1 RNA levels and CD4 cell counts, virological phenotype and the development of phenotypic and genotypic resistance. A total of 47 late-stage, HIV-1-infected, antiretroviral-naive patients treated with reverse transcriptase inhibitors (zidovudine or didanosine monotherapy or alternating zidovudine and didanosine) as part of a randomized study and remaining on treatment for a minimum of 1 year were included in the study. Baseline serum HIV-1 RNA levels did not differ between the patients harbouring syncytium-inducing (SI) virus and those harbouring non-syncytium-inducing (NSI) virus (P = 0.66), despite the fact that the group of patients with SI virus had a significantly lower median CD4 cell count (P < 0.00005) and a higher proportion of patients diagnosed with AIDS at study entry (11/19 versus 6/25) than did the group with NSI virus. The patients harbouring SI virus had significantly faster clinical progression than that of the patients harbouring NSI virus (P < 0.001). The patients wit

OBJECTIVE:To study development of phenotypic and genotypic resistance against zidovudine (ZDV) and didanosine (ddI) during 24 months of mono- and monthly alternating therapy. PATIENTS:Forty-six patients, not previously treated with antiretroviral drugs, were included in the study. METHODS:ZDV and ddI sensitivity were determined in a biological assay based on production of HIV antigen in cultures of CD4+ lymphocytes. The ZDV-associated mutations at codon 41 and 215, and the ddI-associated mutation at codon 74 of the reverse transcriptase (RT) gene were analysed using selective polymerase chain reaction on DNA from peripheral blood mononuclear cells. The biological phenotype [syncytium-inducing (SI)/non-SI(NSI)] of the viral isolates was assessed using a MT2 assay. RESULTS:Of the patients, 82% in ZDV therapy and 73% in alternating therapy developed phenotypic resistant HIV [median inhibitory concentration (IC50) > 0.1 microM]. Patients treated for 1 year with ddI (monotherapy or alternating) had significant higher ddI IC50 values than patients in ZDV monotherapy. During ZDV and alternating therapy, 67 and 75% of the patients, respectively, developed mutations in RT codon 41, whereas 83 and 75%, respectively, developed mutations in codon 215. In patients treated with ddI, 60% developed mutations in codon 74, whereas none of the patients in either alternating ZDV/ddI or ZDV therapy developed this mutation. Forty-six per cent of the patients had SI HIV at start of therapy. Four patients switched from SI to NSI during either ZDV, ddI or alternating therapy. Faster development of resistance was associated with the SI phenotype. CONCLUSIONS:No difference in either phenotypic ZDV or ddI resistance, or genotypic ZDV resistance could be demonstrated during monotherapy or monthly alternating ZDV/ddI therapy, whereas genotypic ddI resistance (mutation in RT codon 74) only were detected in patients in ddI monotherapy. In addition, we found that development of phenotypic and genotypic resistance was faster in patients harbouring SI isolates, and that switches from SI to NSI during therapy was independent of the type of therapy.

In a prospective, randomized open-label trial, the efficacy of sulfamethoxazole-trimethoprim (SMX-TMP) 400/80 mg b.i.d. was compared with the efficacy of aerosolized pentamidine (AP) 60 mg every 2nd week as secondary prophylaxis (SP) against recurrence of Pneumocystis carinii pneumonia (PCP) in AIDS patients. 94 patients participated in the study, 47 in each group. The patients were observed for a mean period of 17.2 months. PCP recurred in the AP group in 8 cases, while 1 relapse occurred in the SMX-TMP group. The one-year cumulative relapse rate was 9.0% (95% CI 0-19%) in the AP group compared with 2.4% (95% CI 0-8%) in the SMX-TMP group (p < 0.05). The odds ratio was 4.2 (95% CI 0.5-39.8) in favour of SMX-TMP. Furthermore, we found a tendency towards a protective effect against toxoplasmosis in the SMX-TMP group, though there was no difference in survival between the two groups. There was no statistical difference in frequency of crossover from one therapy form to the other. Based on these data we recommend SMX-TMP for secondary PCP prophylaxis.

To evaluate polymerase chain reaction (PCR) for detection of Pneumocystis carinii, 117 bronchoalveolar lavage (BAL) specimens, from HIV-infected patients undergoing a diagnostic bronchoscopy, were processed and a nested PCR, followed by Southern blot and hybridization with a P32-labelled probe was performed. The sensitivity and specificity were 85 and 100% 934/40 and 77/77) respectively. A non-radioactive labelling system BluGENE was evaluated on all specimens, and found to be as effective as P32-labelling. To increase the speed and convenience of detection, a dot blot system was tested, but sensitivity dropped markedly with this system. A further 33 patients had both induced sputum and bronchoalveolar lavage performed and the induced sputum was analysed using PCR and routine microbiological methods. The PCR sensitivity on induced sputum was equal to that of routine methods. At present the evaluated PCR cannot replace routine microbiological methods for detection of Pneumocystis carinii, on either BAL fluid or induced sputum.

During the past six years Zidovudine has been the main antiviral drug directed against HIV. The indications for its use have slowly been extended and a reduced dose has limited the side effects. The therapeutical gain is a survival benefit of three to nine months. Other nucleoside analogues such as didanosin and zalcitabin have shown antiviral efficacy but the side effects are different from those of zidovudine. A number of drugs, including protease inhibitors and non-nucleoside reverse transcriptase inhibitors have shown antiviral effects, and are being tested in clinical trials. As no single drug appears to be able to control HIV for an extended period of time, combination regimens including multiple drugs, often administered early in the course of infection, seem to be a promising approaches, which are being pursued in a number of clinical trials.

The effectiveness and tolerability of Sulfamethoxazole with Trimethoprim (SMX-TMP), a dose of 400mg/80mg given twice a day as secondary prophylaxis (SP) against Pneumocystis carinii pneumonia (PCP) was assessed retrospectively in 166 AIDS patients. The mean observation period was 9.7 months (range 1.0-1.4). Relapse of PCP occurred in eight patients; four episodes were histologically verified and four episodes were clinically assumed. The relapse rate after one year of prophylaxis was 5.1% (95% CI 0.0%-11.0%) using the log-rank test. Intolerance of secondary prophylaxis, defined as adverse effects necessitating cessation of SP with SMX-TMP, was reported in eight patients (5%) (95% CI 2.1%-9.3%).

3'-azido-3'deoxythymidine (AZT), a clinically used anti-HIV compound, was evaluated for antiviral effect on HIV infection in combination with other antiviral compounds in vitro. Interactions were evaluated by the median-effect principle and the isobologram technique. Synergistic effect was obtained by combining many evaluated antiviral agents with AZT. We observed a difference in the degree of synergism depending on the evaluated compound; the results indicate that compounds with the same target in the viral replicative cycle (ddI: 2',3'-dideoxyinosine, didanosine; d4T: 2',3'-dideoxy-2',3'-didehydrothymidine stavodine; TIBO: tetrahydro-imidazole-benzodiazepin) had a synergistic effect at all concentrations, agents that disturb the infectivity of virus (CAS: Castanospermine; AME: Amphotericin B Methyl Ester) exerted a strong synergistic effect at low concentrations, and finally compounds interfering with the adhesion/penetration process of virus (ConA: Concanavalin A; DS: dextran sulfate) were most potent with AZT when used in rather high concentrations. At this moment in the HIV epidemic, these observations suggest that combinations of antiviral compounds should be evaluated in clinical trials, with the major emphasis on nucleoside analogues and compounds influencing the infectivity of the virus.