Management Of HIV Patients Research Articles

Modelling response to HIV therapy without a genotype: an argument for viral load monitoring in resource-limited settings

In the absence of widespread access to individualized laboratory monitoring, which forms an integral part of HIV patient management in resource-rich settings, the roll-out of highly active antiretroviral therapy (HAART) in resource-limited settings has adopted a public health approach based on standard HAART protocols and clinical/immunological definitions of therapy failure. The cost-effectiveness of HIV-1 viral load monitoring at the individual level in such settings has been debated, and questions remain over the long-term and population-level impact of managing HAART without it. Computational models that accurately predict virological response to HAART using baseline data including CD4 count, viral load and genotypic resistance profile, as developed by the Resistance Database Initiative, have significant potential as an aid to treatment selection and optimization. Recently developed models have shown good predictive performance without the need for genotypic data, with viral load emerging as by far the most important variable. This finding provides further, indirect support for the use of viral load monitoring for the long-term optimization of HAART in resource-limited settings.

Delivering integrated HIV services: time for a client-centred approach to meet the sexual and reproductive health needs of people living with HIV?

Delivering integrated HIV services: time for a client-centred approach to meet the sexual and reproductive health needs of people living with HIV?

Risk factors for HIV-associated neurocognitive disorders (HAND) in sub-Saharan Africa: The case of Yaoundé-Cameroon

Background The prevalence of HIV-associated neurocognitive disorders (HAND), especially HIV-associated dementia (HAD) is influenced by several risk factors. The prevalence as well as risk factors for HAD are not well known in sub-Saharan Africa (SSA). We have shown that the International HIV Dementia Scale (IHDS) is a useful screening tool for HAND in Yaoundé [Njamnshi AK, Djientcheu VdP, Fonsah JY, Yepnjio FN, Njamnshi DM, Muna WFT. The IHDS is a useful screening tool for HAD/Cognitive Impairment in HIV-infected adults in Yaoundé-Cameroon. Journal of Acquired Immune Deficiency Syndromes 2008;49(4):393–397], but no study in Cameroon has yet investigated the risk factors for HAND or HAD. Patients and methods A cross-sectional study was conducted in Yaoundé, the capital of Cameroon from September to December 2006. One hundred and eighty-five HIV-positive subjects were included. Diagnosis of HAND was done using the IHDS with a score ≤ 10 considered as abnormal. Age, sex, level of education, IV drug use, body mass index (BMI), CDC clinical stage, CD4 counts, hemoglobin levels, administration of highly active antiretroviral therapy (HAART) and type of regimen used, were considered in univariate analysis, with level of significance set at P ≤ 0.05. A binary logistic regression was used to determine independent risk factors. Results The following factors were independent predictors of HAND: advanced clinical stage (OR = 7.43, P = 0.001), low CD4 count especially CD4 ≤ 200 cells/µL (OR = 4.88, P = 0.045) and low hemoglobin concentration (OR = 1.16, P = 0.048). Conclusion This first study of the risk factors for HAND in Yaoundé-Cameroon shows findings similar to those described in other studies. These results call for rapid action by policy makers to include HAND prevention strategies such as providing early universal access to HAART based on these risk factors, in the management of HIV patients at risk of HAND in resource-limited settings of SSA like ours.

Metabolic bone disease in HIV infection

HIV mainly replicates in CD4þ T lymphocytes andmonocyte/macrophages causing severe immunologicalimpairment. In addition to the immune system, HIVinfection affects tissues and organs such as kidney, liver,the central nervous system, heart and bone showing acomplex pathogenesis [1].The advent and widespread use of highly activeantiretroviral therapy (HAART) in the last two decadeshasled toa markedimprovementinthe treatmentofHIVdisease even though viral infection cannot be eradicatedbecause HAART does not completely eliminate the viralreservoirs [2]. HAART has dramatically changed thecourseofHIVinfection froma fatalinfectiontoachronicand relatively manageable disease. The increased lifeexpectancyofHIVpatientsandtheeffectsofHAARThavechanged the management of HIV infection. Nowadaysmedical treatment is no longer focused solely on HIVinfection, opportunistic diseases and monitoring immunederangement, but also includes the control of metabolic,cardiovascular, liver, bone and kidney complications. Inparticular, bone alterations have been observed in thecourse of HIV disease representing a pivotal clinicalprobleminthemanagementofHIVpatientsespeciallyforapossible development of bone fractures [3]. The majorbonelesionsdetectableinHIVpatientsarerelatedtobonedemineralization (osteopenia/osteoporosis and osteoma-lacia) and osteonecrosis ([4] for a review).This report will discuss the pathogenesis, diagnosis andtreatment of major bone complications represented bybone demineralization diseases during HIV infection andHAART treatment.

Survey of physician knowledge regarding antiretroviral medications in hospitalized HIV‐infected patients

BackgroundAntiretroviral prescribing errors are common among hospitalized patients. Inadequate medical knowledge is likely one of the factors leading to these errors. Our objective was to determine the proportion of hospital physicians with knowledge gaps about prescribing antiretroviral medications for hospitalized HIV-infected patients and to correlate knowledge with length and type of medical training and experience.MethodsWe conducted an electronic survey comprising of ten clinical scenarios based on antiretroviral-prescribing errors seen at two community teaching hospitals. It also contained demographic questions regarding length and type of medical training and antiretroviral prescribing experience. Three hundred and forty three physicians at both hospitals were asked to anonymously complete the survey between February 2007 and April 2007.ResultsOne hundred and fifty-seven physicians (46%) completed at least one question. The mean percentage of correct responses was 33% for resident physicians, 37% for attending physicians, and 93% for Infectious Diseases or HIV (ID/HIV) specialist physicians. Higher scores were independently associated with ID/HIV specialty, number of outpatients seen per month and physician reported comfort level in managing HIV patients (P < .001).ConclusionNon-ID/HIV physicians had uniformly poor knowledge of common antiretroviral medication regimens. Involvement of ID/HIV specialists in the prescribing of antiretrovirals in hospitalized patients might mitigate prescribing errors stemming from knowledge deficits.

Role of the dentist in the management of patients with HIV/AIDS

The clinical problem of HIV infection poses one of the greatest challenges to Health Care Workers (HCW) all over the world. AIDS, since its appearance in 1981 has spread to become a major cause of premature death and so far, a cure is yet to be found. Its mode of spread poses special danger to HCW particularly the dentists who have close contact with the patients. This paper examines the relationship between HIV and dentistry; the role of the dentist, the size of the pandemic and its implication to the dental profession, especially regarding infection control. Ethical issues in the management of HIV patients are also addressed by highlighting areas of conflict. The aim of this paper is to educate and sensitize the dentist and the dental team to these issues as they relate to occupational exposure and suggest ways of resolving areas of conflict. This is to ensure that neither patient management, the health of the HCW nor their practice is compromised in any way. Keywords: HIV/AIDS, dentist, managementNigerian Dental Journal Vol. 15 (2) 2007: pp. 61-65

The EuroSIDA Study: Regional Differences in the HIV-1 Epidemic and Treatment Response to Antiretroviral Therapy among HIV-infected Patients across Europe - A Review of Published Results

EuroSIDA is a pan-European observational study that follows 14,265 HIV-infected patients from 31 European countries, Israel and Argentina, of which 2,560 are patients from eastern Europe (EE). The study group has performed several analyses addressing regional differences in the HIV-epidemic across Europe, where all countries were divided into five regions: south, west central, north, east central Europe and EE. Significant regional differences in patients' characteristics and pattern of AIDS diagnoses were documented. More patients from EE were diagnosed with tuberculosis compared to other regions. Significantly fewer HIV-infected patients in EE, who fulfilled the criteria for starting combination antiretroviral therapy (cART), actually received cART as compared with other regions of Europe. Those, receiving cART in EE had a lower initial virologic response rate irrespectively of the regimen used, although it has improved within years. Besides, treatment failure was more common in this region. Thus, improvements in the clinical management of HIV patients in EE are urgently needed. Strategies include creating scientific collaborations for HIV clinicians as well as teaching clinicians about the most advanced HIV management at clinically oriented courses held in eastern Europe.

Fatal disseminated toxoplasmosis with congenital transmission in an African migrant

Migrants from HIV-endemic areas may be newly diagnosed with HIV in Western countries. A 27-year-old pregnant woman from sub-Saharan Africa presented with disseminated fatal toxoplasmosis and congenitally transmitted the parasite. Despite medical care maternal infection was only diagnosed postmortem and diagnosis in the newborn was delayed. Problematic aspects of medical care in migrants in Western countries are discussed. (excerpt)

The significance of activation markers on CD8 lymphocytes in human immunodeficiency syndrome: staging and prognostic value

The objective of this prospective cohort study was to evaluate the expression of activation markers on CD8 lymphocytes at various clinical stages of HIV infection and to determine the value of these markers in identifying patients likely to have rapidly progressive disease. One hundred and three HIV+ patients, divided into four disease stages, and 34 seronegative controls were evaluated at study entry using flow cytometric immunophenotyping. The HIV patients were followed clinically for disease progression during the following 2 years. CD8 cell numbers and percentage of lymphocytes are increased after HIV infection. Expression of the CD38, HLA-DR and CD57 markers on CD8 cells was significantly increased in asymptomatic HIV-infected patients when compared with controls, as was the CD8 cell population which did not coexpress Leu-8. These activation markers were observed to be further increased in patient groups with more clinically advanced infection. The percentage of CD38 on CD8 cells emerged not only as a discriminator of disease severity, but was a strong predictor of progression in asymptomatic, lymphadenopathy and ARC patients. Given the utility of activation markers on CD8 lymphocytes in staging disease and predicting clinical outcome, the measurement of these parameters should be considered in the monitoring and management of HIV patients.

CD4+ T‐lymphocyte enumeration with a flow‐rate based method in three flow cytometers with different years in service

CD4(+) T-lymphocyte count remains the most important surrogate marker for management of HIV patients in resource-poor countries. The standard single-platform (SP) bead-based flow cytometric method for CD4(+) testing is expensive; more affordable methods are needed. We evaluated the SP flow-rate-based calibration method for determining CD4(+) counts, using three flow cytometers of varying ages. CD4(+) counts from 103 HIV-1 infected Thai patients were determined using a SP flow-rate method in flow cytometers with 2, 12, and 16 years of service. Results were compared to the bead-based method. Correlation and agreement were analyzed using linear regression and Bland-Altman analysis. Counts obtained from the flow-rate approach in each flow cytometer showed strong correlation with the bead-based method (R(2) = 0.97, 0.97, and 0.96 for the 2-, 12-, and 16-year-old flow cytometers). The mean biases for the flow-rate approach compared with the bead-based method were +32.4 cells/microL (limit of agreement (LOA): -83.0 to +147.8 cells/microL), -28.8 cells/microL (LOA: -131.6 to +74.1 cells/microL), and -27.0 cells/microL (LOA: -149.4 to +95.4 cells/microL). The flow-rate approach is reliable for determining CD4(+) counts. Results do not vary by age of flow cytometer. This approach provides a cost-effective alternative for HIV patient monitoring in resource-poor settings.

Osteopenia and osteoporosis in HIV: pathogenesis and treatment

Since the introduction of potent antiretroviral therapy, the emphasis in managing HIV patients has changed from treatment and prevention of opportunistic infections to dealing with toxicities of long-term antiretroviral therapy such as bone demineralization. To date, the pathogenic mechanisms underlying the initiation and progression of osteoporosis in HIV patients remain to be elucidated. This review focuses on recent advances in our understanding of the role of both HIV and antiretroviral therapy in driving bone disease and presents an update on current treatment options and new therapeutic agents targeting novel sites. Recent studies explored the role of HIV and individual antiretroviral therapy drugs in modifying the phenotype of bone cells. Studies have demonstrated effects on cell differentiation, maturation and function in response to both HIV and its treatment - effects mediated via direct alterations in both cell signaling and gene and protein expression. Evidence from clinical and cell biological investigations has demonstrated the importance of both HIV and antiretroviral therapy in the emergence of osteoporotic bone disease. Continued efforts aimed at deciphering the molecular basis of metabolic bone disease in HIV patients are necessary to ensure optimal treatment of current patients and to create novel therapeutic interventions.

Private practitioners' communications with patients around HIV testing in Pune, India

Unlike any other disease so far, the 'exceptional' nature of HIV/AIDS has prompted debate about the necessity, but also the challenges, of regulating practitioner-patient communication around HIV testing. In India, the National AIDS Control Organization (NACO) has adopted the guidelines of the World Health Organization with regard to HIV testing and counselling, yet the extent to which these guidelines are fully understood or followed by the vast private medical sector is unknown. This paper examines the gaps between policy and practice in communications around HIV testing in the private sector and aims to inform a bottom-up approach to policy development that is grounded in actual processes of health care provision. Drawing on 27 in-depth interviews conducted with private medical practitioners managing HIV patients in the city of Pune, we looked specifically at practitioners' reported communications with patients prior to an HIV test, during and following disclosure of the test result. Among these practitioners, informed consent is rare and pre-test communication is prescriptive rather than shared. Confidentiality of the patient is often breached during disclosure, as family members are drawn into the process without consulting the patient. While non-adherence to guidelines is a matter of concern, practitioners' communication practices in this setting must be understood in the given social and legal context of the patient-practitioner relationship in India. Communication with their patients is strongly influenced by practitioners' perceptions of their own roles and relationships with patients, perceived characteristics of the patient population, limitations in knowledge and skills, moral values as well as perceptions of legal guidelines and patient rights. We suggest that policy guidelines around patient-practitioner communication need to take sufficient cognizance of existing practices, cultures and the realities of care provision in the private sector. Patients themselves need to be empowered in order to grasp the importance and implications of HIV testing and counselling.

Premature atherosclerosis in HIV positive patients and cumulated time of exposure to antiretroviral therapy (SHIVA study)

Background With the advent of antiretroviral therapy regimens in HIV positive patients, it is crucial to consider their long-term benefits to risk ratios. The responsibility of treatment in premature atherosclerosis is not clear. Thus, the aim of this study is to evaluate the impact of exposure to reverse transcriptase inhibitors (nucleosidic and non-nucleosidic) and to protease inhibitors on the cardiovascular status of an entire hospital based cohort of patients. Methods 154 patients were included. Using a linear analysis, we sought an association between the cumulative time of exposure to these three classes of antiretroviral drugs and the carotid intima-media thickness measured by ultrasonography and a cardiovascular composite score. Results The study confirms premature atherosclerosis, which not only correlates with the usual risk factors, such as triglyceride level, but also with protease inhibitor exposure, especially that of lopinavir. Nevertheless as regards current drug exposure, the clinical impact was low: five clinical complications of atherosclerosis and only one out of 35 scintigraphic and ECG exercise tests warranted a coronary angiography which was negative. Conclusion These data should not lead to the rejection of protease inhibitors but should strengthen the prevention of cardiovascular diseases as an integral part of the management of HIV patients.

Expanding Access to the Management of HIV/AIDS through Physicians in Private Practice: An Exploratory Survey of Knowledge and Practices in Two Nigerian States

Over the past few years, the cost of antiretroviral drugs has continued to decline. A significant proportion of people in Nigeria seek medical care primarily in the "for profit" private sector. The complexity of managing HIV and AIDS has led to debates on whether care should only be restricted to trained and accredited experts in HIV care. This research studied the knowledge and practices of physicians in private practice in two Nigerian states on the management of patients with HIV/AIDS using an anonymous self-administered questionnaire eliciting knowledge and attitudinal information. This is to ascertain their preparedness to manage HIV positive patients. The doctors were found to be poorly informed on practical issues in the management of HIV patients. These included the need to confirm their patient's HIV status, where to do the confirmation and where to refer such patients for counselling. Most of them referred to the mass media as their primary source of information. There is an urgent need for pro-active planning to prepare physicians in private practice for increasing demands in the management of HIV/AIDS in Nigeria. Organising a nation-wide training programme that would lead to ongoing accreditation programme is a way of achieving this. The formulation of guidelines for managing both clinical and non-clinical aspects of HIV/AIDS should be prioritised.

Managing uncertainty around HIV/AIDS in an urban setting: Private medical providers and their patients in Pune, India

Changing epidemiological patterns and the advent of new rapid diagnostic technologies and therapies have created considerable uncertainty for providers working in HIV. In India, the demand for HIV care is increasingly being met by private practitioners (PPs), yet little is known about how they deal with the challenges of managing HIV patients. To explore HIV management practices in the private medical sector, a survey was conducted with 215 PPs in Pune, India, followed by in-depth interviews focusing on the social context of practice among a sub-set of 27 PPs. Drawing primarily on interview data, this paper illustrates a number of uncertainties that underlie the reported actions of providers in a competitive medical market. PPs perceive HIV as a ‘new’ and challenging disease for which they lack adequate knowledge and skills. Combined with the perceived high cost and complexity of antiretroviral treatment, preconceptions about HIV patients’ social, financial and mental capacity lead to highly individualistic management practices. While these fall short of clinical ‘best practice’ guidelines, they reflect adaptive responses to the wider uncertainties surrounding HIV care in urban India. By highlighting contextual issues in PPs’ management of HIV patients, the paper suggests the need to explicitly acknowledge the social, moral and economic bases of uncertainty beyond the clinical setting.

Usefulness of Therapeutic Drug Monitoring of Antiretrovirals in Routine Clinical Practice

Background: Clinical trials have shown that therapeutic drug monitoring (TDM) of antiretrovirals (ARV) improves patient care. However, little is known about the usefulness of TDM in routine practice. Method: We reviewed all the trough concentrations of protease inhibitors and nonnucleoside reverse transcriptase inhibitors that were performed for therapeutic failure, suspected drug toxicity, or routine purposes. Results: Between 1998 and 2001, 146 TDMs were done in 109 HIV patients. Of the 48 patients with therapeutic failure, 62% had resistance to ARV with adequate ARV concentrations, 16% had insufficient drug exposure without any ARV resistance mutations, and 16% combined both resistance and suboptimal drug concentrations. Subsequent therapeutic interventions (increasing adherence and/or changing HAART) resulted in an undetectable viral load in 37.5% of the patients (14/48). Five (24%) of 21 patients with suspected drug toxicity had high drug concentrations associated with side effects. In all the cases, adverse events regressed after reduction of drug dosage. Of the 77 TDMs done for routine purposes, 26% were outside the therapeutic range. Conclusion: The data show that TDM of ARVs in the clinical setting provides important information that can be used to improve the management of HIV patients receiving antiretroviral therapy.

The AIDS Knowledge Base, 3rd edition, 1999Edited by CohenP.T., SandeM.A. and VolberdingP.A.. Publishers: Lippincott Williams &amp; Wilkins, P.O. Box 1640, Hagerstown, MD 21741-1640. Price: $125.00. ISBN: 0-316-14903-9.

Book ReviewsThe AIDS Knowledge Base, 3rd edition, 1999 Fahad Al RabiahMD Fahad Al Rabiah Consultant, Infectious Diseases, Department of Medicine, MBC 46, King Faisal Specialist Hospital and Research Centre, P.O. Box 3354, Riyadh 11211, Saudi Arabi Search for more papers by this author Published Online:1 Jan 2000https://doi.org/10.5144/0256-4947.2000.91SectionsPDF ToolsAdd to favoritesDownload citationTrack citations ShareShare onFacebookTwitterLinked InRedditEmail AboutIntroductionInfectious disease specialists, especially those who are interested in HIV/AIDS, know The AIDS Knowledge Base very well. This new edition is a multi-author book, consisting of contributions from more than one hundred known and experienced physicians in North America. The book is large, consisting of 966 pages, and divided into nine sections, with each section containing a varying number of chapters, and totalling 86 chapters in all.Section 1 of the book covers epidemiology and transmission of HIV, and the authors recount details of epidemiology in the United States and other countries. Section 2 provides a comprehensive review on testing for HIV. Section 3 covers basic science and pathogenesis of HIV. Section 4 deals with the natural history, clinical spectrum and general management of. HIV disease. Section 5 covers clinical manifestation of HIV disease. Section 6 provides detailed information about infection associated with HIV disease. Section 7 deals with malignancies associated with HIV disease, and section 8 deals with ethical-legal and economic issues of HIV disease. Lastly, Section 9 deals with prevention and education, especially for occupational and non-occupational HIV exposure prophylaxis and management.There have been major advances in the knowledge of HIV, as well as changes in management of HIV patients, and there have also been major changes in patients' and health care providers' perceptions of HIV/AIDS. The authors of The AIDS Knowledge Base have included recent published research and expert opinion, which is an improvement on the previous edition of 1994. The overall organization of the book is unchanged from previous editions, and includes major sections with specific chapters on infections and malignancies, as well as problems discussed by system or anatomical region, and various aspects of the general management of HIV. The authors elected not to include a section on pediatric HIV disease, since there are several comprehensive textbooks devoted to this specialty.The AIDS Knowledge Base is entirely clinic oriented, focusing on many issues, including patient management of the disease from all its aspects. There are many tables in the book, which were designed to help in understanding complicated concepts and give comprehensive overviews of current literature.In summary, this book can be regarded as a major reference for HIV and AIDS, and the authors should be commended for compiling it. I believe that all infectious disease physicians and clinicians who deal with HIV patients should have this valuable book, which is very affordable at a price of US$ 125. Previous article Next article FiguresReferencesRelatedDetails Volume 20, Issue 1January 2000 Metrics History Published online1 January 2000 InformationCopyright © 2000, Annals of Saudi MedicinePDF download

Association of HIV viral load with oral diseases.

The measurement of HIV viral load as a predictor of disease progression has revolutionized the medical management of HIV patients. In this study, oral diseases as measured by DMFT (decayed, missing and filled teeth), periodontal assessment and oral Candidacolonization, were related to HIV viral load. Also correlated was HIV status assessments, including CD4+ count, a history of intravenous drug abuse (IVDA) and the use of protease inhibitor drugs. Oral and periodontal examination, dental radiographs, and tongue swab for fungal culture was accomplished over a 2-month period on 39 HIV positive patients attending the University of Maryland Dental School. Twenty-eight (71. 8%) of these patients had a history of IVDA. Viral load was measured by a quantitative RT-PCR. Among the patients with high viral load (>10 000 copies ml-1), 92.3% were found to have a history of IVDA. Also, patients with high viral load demonstrated average CD4+ counts of 136 mm-3 while moderate viral load (400-10 000 copies ml-1) corresponded to average counts of 271 mm-3. Periodontal pocket depths (PPD) of >5 mm at a minimum of two oral sites were found in 76.9% of the patients with high viral load. Among the high viral load patients, 69.2% had DMFT >20, 69.2% were culture positive for Candida and 81.5% of patients on protease inhibitors demonstrated moderate or low viral loads. These data demonstrated that elevated viral load levels correlate well with oral disease prevalence in this predominantly IVDA population of HIV-infected dental patients.

Micronutrients and HIV infection: a review.

Malnutrition is a cardinal clinical manifestation of acquired immunodeficiency syndrome (AIDS) but even early asymptomatic human immunodeficiency virus type-1 (HIV) infection may lead to impaired nutritional status. However impaired nutritional status is not only a characteristic of HIV/AIDS in parallel to immunodeficiency. Micronutrient deficiencies may impair host immunonefunctions and affect viral replication and pathogenicity thus potentially affecting transmission and clinical course of infection. Therefore improved nutrition may play a role in sexual and mother-to-child HIV transmission progression of HIV to AIDS as well as mortality from AIDS. Although dietary counselling or provision of an optimal diet is important in the case management of HIV patients this is generally not an option in developing countries harbouring the vast majority of the worlds HIV infected individuals. In developing countries however micronutrient supplementation via the primary health care system to high-risk populations may be an operationally feasible and affordable public health measure. This paper reviews the literature on micronutrients and HIV infection and discusses the potential role of increased micronutrient intake as a measure to reduce HIV transmission and progression. (excerpt)

S181 Application of pharmacokinetics in the management of HIV patients

S181 Application of pharmacokinetics in the management of HIV patients