HIV/hepatitis C virus and HIV/hepatitis B virus coinfections protect against antiretroviral-related hyperlipidaemia

Introduction

Hyperlipidaemia is a recognized complication of HIV antiretroviral therapy. The interactions among HIV, viral hepatitis, antiretroviral therapies and lipids are poorly understood.

Methods

Ontario HIV Treatment Network Cohort Study participants with at least one lipid level after highly active antiretroviral therapy (HAART) initiation were assessed. Hepatitis B virus (HBV)‐ and hepatitis C virus (HCV)‐coinfected patients were identified by serology or chart review. HCV antiviral recipients, diabetics and those on lipid‐lowering drugs at baseline were excluded from the study. Factors associated with a decreased risk of grade 3 or 4 hyperlipidaemia or lipid‐lowering drug use were assessed by multivariate logistic regression.

Results

A total of 1587 HIV‐monoinfected, 190 HIV/HBV‐coinfected and 255 HIV/HCV‐coinfected patients were evaluated. Most were male (85–92% for the 3 groups evaluated: HIV, HIV/HBV, HIV/HCV). The median [interquartile range (IQR)] age at HAART initiation was 48 (44–56) years and was similar between groups. The median (IQR) CD4 count at HAART initiation was 245 (120–370) cells/μL in HIV‐monoinfected participants, 195 (110–330) cells/μL in HIV/HBV‐coinfected participants and 268 (140–409) cells/μL in HIV/HCV‐coinfected participants. Factors associated with a decreased risk of grade 3 or 4 hyperlipidaemia or lipid‐lowering drug use included HIV/HCV coinfection [odds ratio (OR) 0.46; 95% confidence interval (CI) 0.34, 0.61; P<0.0001], HIV/HBV coinfection (OR 0.74; 95% CI 0.55, 0.99; P=0.04), year of starting HAART after 2004 vs. 1997 or earlier (OR 0.37; 95% CI 0.29, 0.48; P<0.0001) and year of starting HAART between 1998 and 2003 vs. 1997 or earlier (OR 0.75; 95% CI 0.61, 0.92; P<0.01). Factors associated with increased risk included age (OR 1.55; 95% CI 1.39, 1.72; per 10 years, P<0.0001) and male gender (OR 1.84; 95% CI 1.36, 2.48; P<0.0001).

Conclusions

HIV/HCV and to a lesser extent HIV/HBV coinfections are protective against HAART‐related hyperlipidaemia.     

Nonconcordance between subclinical atherosclerosis and the calculated Framingham risk score in HIV‐infected patients: relationships with serum markers of oxidation and inflammation

Objectives

HIV‐infected patients show an increased cardiovascular disease (CVD) risk resulting, essentially, from metabolic disturbances related to chronic infection and antiretroviral treatments. The aims of this study were: (1) to evaluate the agreement between the CVD risk estimated using the Framingham risk score (FRS) and the observed presence of subclinical atherosclerosis in HIV‐infected patients; (2) to investigate the relationships between CVD and plasma biomarkers of oxidation and inflammation.

Methods

Atherosclerosis was evaluated in 187 HIV‐infected patients by measuring the carotid intima‐media thickness (CIMT). CVD risk was estimated using the FRS. We also measured the circulating levels of interleukin‐6, monocyte chemoattractant protein‐1 (MCP‐1) and oxidized low‐density lipoprotein (LDL), and paraoxonase‐1 activity and concentration.

Results

There was a weak, albeit statistically significant, agreement between FRS and CIMT (κ=0.229, P<0.001). A high proportion of patients with an estimated low risk had subclinical atherosclerosis (n=66; 56.4%). In a multivariate analysis, the presence of subclinical atherosclerosis in this subgroup of patients was associated with age [odds ratio (OR) 1.285; 95% confidence interval (CI) 1.084–1.524; P=0.004], body mass index (OR 0.799; 95% CI 0.642–0.994; P=0.044), MCP‐1 (OR 1.027; 95% CI 1.004–1.050; P=0.020) and oxidized LDL (OR 1.026; 95% CI 1.001–1.051; P=0.041).

Conclusion

FRS underestimated the presence of subclinical atherosclerosis in HIV‐infected patients. The increased CVD risk was related, in part, to the chronic oxidative stress and inflammatory status associated with this patient population.

     

Poor adherence to HIV monitoring and treatment guidelines for HIV-infected injection drug users

Objectives

There is growing concern about access to HIV/AIDS care among injection drug users (IDUs). We examined rates of CD4 cell count monitoring and correlates among HIV‐infected IDUs.

Methods

This prospective observational cohort study of 460 community‐recruited HIV‐infected IDUs was situated in a Canadian city where all medical care is provided free of charge. Over a median follow‐up period of 76 months, we evaluated factors associated with CD4 cell count monitoring through a linkage with a centralized CD4 registry.

Results

Overall, <5% of IDUs had CD4 monitoring consistent with local therapeutic guidelines. In multivariate analyses, after adjustment for being on antiretroviral therapy [odds ratio (OR) 2.21, 95% confidence interval (CI) 1.84–2.70, P<0.001] female gender (OR 0.71, 95% CI 0.57–0.89, P=0.003), non‐White ethnicity (OR 0.75, 95% CI 0.60–0.94, P=0.014), use of methadone maintenance therapy (OR 1.66, 95% CI 1.42–1.94, P<0.001) and daily heroin use (OR 0.72, 95% CI 0.61–0.85, P<0.001) were independently associated with CD4 monitoring.

Conclusions

Strategies to improve CD4 surveillance among IDUs are critically important, particularly for female and non‐White IDUs. Expanded treatment for heroin dependence appears to have the greatest potential for improved care.     

Association between HIV infection and attenuated diurnal blood pressure rhythm in untreated hypertensive individuals*

Objective

Hypertensive cardiovascular complications are more closely associated with ambulatory blood pressure (ABP), particularly the attenuated diurnal blood pressure (BP) rhythm (i.e. a fall in systolic blood pressure <10% during the night compared with the day), than with casual BP. The aim of the study was to assess the ABP pattern in an HIV‐infected cohort in which hypertension was newly diagnosed.

Methods

ABP over 24 h was compared between 77 newly diagnosed, untreated hypertensive HIV‐positive individuals and 76 HIV‐uninfected untreated hypertensive controls.

Results

More HIV‐infected subjects had an attenuated ABP rhythm with a reduced nocturnal fall than HIV‐negative hypertensive control subjects (60 vs. 33%, respectively; P=0.001). The dipping pattern was observed despite newly diagnosed hypertension, a low prevalence of microalbuminuria, and the absence of signs of overt kidney disease. Furthermore, the prevalence of nondipping in the HIV‐infected subjects was independent of combination antiretroviral treatment. Multiple logistic regression analysis with dipping pattern as the dependent variable showed that HIV status was an independent predictor of nondipping BP [P=0.002; odds ratio (OR) 0.33; 95% confidence interval (CI) 0.17–0.66]; casual SBP (P=0.37; OR 1.001; 95% CI 0.99–1.04) and microalbuminuria (P=0.39; OR 1.56; 95% CI 0.57–4.28) were not associated with dipping pattern.

Conclusions

The prevalence of a nondipping BP pattern in HIV‐infected subjects with newly diagnosed hypertension who had not received antihypertensive treatment was high and significantly greater than in hypertensive control subjects.     

Nevirapine- versus efavirenz-based highly active antiretroviral therapy regimens in antiretroviral-naïve patients with advanced HIV infection

Objective

To compare virological and immunological responses to nevirapine (NVP)‐based and efavirenz (EFV)‐based highly active antiretroviral therapy (HAART) regimens in antiretroviral‐naïve patients with advanced HIV infection.

Methods

A retrospective observational cohort study was conducted on antiretroviral‐naïve HIV‐infected patients whose pretreatment CD4 cell counts were less than 100 cells/μL or whose viral loads were greater than 100 000 HIV‐1 RNA copies/mL.

Results

Baseline characteristics of patients in the NVP (n=24) and EFV (n=29) groups were not different. The proportion of patients with viral loads >100 000 copies/mL was higher in the EFV group. The probability of virological success estimated by the Kaplan‐Meier method showed that 3‐ and 6‐month success rates were 30.8% [95% confidence interval (CI): 16.7–52.2%] and 63.1% (95% CI: 44.7–81.3%) for the NVP group. The corresponding values were 41.2% (95% CI: 25.8–61.0%) and 62.9% (95% CI: 45.7–80.1%) for the EFV‐based group. The median success times of the two groups were about 4 and 3 months (P=0.678), respectively, for NVP and EFV. Cox's proportional hazard was used after adjusting for age, previous opportunistic infections (OIs), and viral load at baseline, and showed that patients who received the NVP‐based regimen had about 25% [hazard ratio (HR)=0.75, 95% CI: 0.37–1.51] less chance of virological success than patients who received the EFV‐based regimen (P=0.415). The median times to CD4≥100 cells/μL were 5.6 and 4.4 months for the NVP‐ and EFV‐based regimens, respectively (log‐rank test, P=0.144).

Conclusions

NVP‐ and EFV‐based HAART regimens as initial regimens in patients with advanced HIV infection are effective and comparable, in term of virological and immunological responses. However, further large‐scale randomized controlled clinical trials in this group of patients with advanced HIV infection are needed.

     

Hepatitis B or hepatitis C coinfection in HIV-infected pregnant women in Europe

Objectives

The aim of the study was to investigate the prevalence of and risk factors for hepatitis C or B virus (HCV or HBV) coinfection among HIV‐infected pregnant women, and to investigate their immunological and virological characteristics and antiretroviral therapy use.

Methods

Information on HBV surface antigen (HBsAg) positivity and HCV antibody (anti‐HCV) was collected retrospectively from the antenatal records of HIV‐infected women enrolled in the European Collaborative Study and linked to prospectively collected data.

Results

Of 1050 women, 4.9% [95% confidence interval (CI) 3.6–6.3] were HBsAg positive and 12.3% (95% CI 10.4–14.4) had anti‐HCV antibody. Women with an injecting drug use(r) (IDU) history had the highest HCV‐seropositivity prevalence (28%; 95% CI 22.8–35.7). Risk factors for HCV seropositivity included IDU history [adjusted odds ratio (AOR) 2.92; 95% CI 1.86–4.58], age (for ≥35 years vs. <25 years, AOR 3.45; 95% CI 1.66–7.20) and HBsAg carriage (AOR 5.80; 95% CI 2.78–12.1). HBsAg positivity was associated with African origin (AOR 2.74; 95% CI 1.20–6.26) and HCV seropositivity (AOR 6.44; 95% CI 3.08–13.5). Highly active antiretroviral therapy (HAART) use was less likely in HIV/HCV‐seropositive than in HIV‐monoinfected women (AOR 0.34; 95% CI 0.20–0.58). HCV seropositivity was associated with a higher adjusted HIV RNA level (+0.28log₁₀ HIV‐1 RNA copies/mL vs. HIV‐monoinfected women; P=0.03). HIV/HCV‐seropositive women were twice as likely to have detectable HIV in the third trimester/delivery as HIV‐monoinfected women (AOR 1.95; P=0.049).

Conclusions

Although HCV serostatus impacted on HAART use, the association between HCV seropositivity and uncontrolled HIV viraemia in late pregnancy was independent of HAART.     

Impact of long-term treatment with neurotoxic dideoxynucleoside antiretrovirals: implications for clinical care in resource-limited settings

Objectives

A minority of HIV‐infected patients taking an antiretroviral (ARV) regimen containing dideoxynucleosides (d‐drugs) such as stavudine (d4T) and didanosine (DDI) experiences dose‐limiting neuropathic pain and paraesthesias, usually within weeks of starting these drugs. Because d‐drugs are among the few affordable options available in developing countries, continuing d‐drug therapy would be a desirable strategy for many HIV‐infected individuals. Therefore, we evaluated the safety of continuing d‐drug therapy.

Methods

In a US cohort, we compared the rates of worsening neuropathic symptoms and signs in HIV‐infected individuals on stable ARV regimens that did (n=252) or did not (n=250) include d‐drugs. Rates of worsening were compared using proportional hazards model and the log‐rank test.

Results

The risk ratios (RR) were not significantly larger for worsening neuropathy signs [0.94; 95% confidence interval (CI) 0.84–1.07] or symptoms (0.99; 95% CI 0.88–1.14) in patients taking d‐drugs continuously compared to those not taking d‐drugs.

Conclusions

Continued d‐drug exposure among patients tolerating an initial trial did not increase the risk of worsening neuropathy compared to non‐d‐drug‐containing regimens. If applicable in developing countries, these findings suggest that in most patients d‐drugs can be continued safely in the long term without increasing the risk of worsening neuropathy.     

Persistently normal alanine aminotransferase levels in HIV/HCV-coinfected patients: the role of steatosis

Objective

The frequency and significance of, and liver biopsy findings associated with, a persistently normal alanine aminotransferase (ALT) level in HIV/hepatitis C virus (HCV)‐coinfected patients are poorly characterized. We analysed factors associated with persistently normal ALT levels, defined as at least three consecutive normal ALT values over a 6‐month period, in a group of 381 HIV/HCV‐coinfected patients.

Methods

Patients were categorized into two groups according to ALT values: group 1, patients with persistently normal ALT levels; and group 2, patients with elevated ALT values. Possible interactions with host factors, HIV and HCV viral factors, antiretroviral treatment and histological features were examined.

Results

Thirty‐six patients (9.4%) had persistently normal ALT levels. None of the 36 patients had cirrhosis. Seven patients (19.4%) had a METAVIR fibrosis score of F3. In multivariate analysis, a lower mean METAVIR inflammation score [odds ratio (OR) 0.50, 95% confidence interval (CI) 0.28–0.89; P=0.017], the absence of steatosis (OR 0.43, 95% CI 0.20–0.90; P=0.026) and HCV genotype 4 infection (OR 2.81, 95% CI 1.15–6.68; P=0.023) were associated with persistently normal ALT levels.

Conclusion

The slower progression of chronic hepatitis in patients with persistently normal ALT levels could be related, in part, to a lower frequency of steatosis

     

High rates of active hepatitis B and C co-infections in HIV-1 infected Cameroonian adults initiating antiretroviral therapy

Objectives

To investigate the presence of hepatitis B virus (HBV) DNA and hepatitis C virus (HCV) RNA in HIV‐infected patients initiating antiretroviral therapy in Cameroon.

Methods

Baseline blood samples from 169 patients were tested retrospectively for hepatitis B surface antigens (HBsAg), anti‐hepatitis B core (anti‐HBc), anti‐HCV and – if HBsAg or anti‐HCV result was positive or indeterminate – for HBV DNA or HCV RNA, respectively, using the Cobas Ampliprep/Cobas TaqMan quantitative assay (Roche Diagnostics GmbH, Mannheim, Germany).

Results

HBV DNA was detected in 14 of the 18 patients with positive or indeterminate HBsAg results [8.3% of the total study population, 95% confidence interval (CI) 4.6–13.5]. The median HBV viral load was 2.47 × 10⁷ IU/mL [interquartile range (IQR) 3680–1.59 × 10⁸; range 270 to >2.2 × 10⁸]. Twenty‐one patients (12.4%, 95% CI 7.9–18.4) were found with HCV RNA (all with positive HCV serology). The median HCV viral load was 928 000 IU/mL (IQR 178 400–2.06 × 10⁶; range 640–5.5 × 10⁶). No patient was co‐infected with HBV and HCV. In multivariate analysis, HCV co‐infection was associated with greater age [≥45 years vs. <45 years, odds ratio (OR) 11.89, 95% CI 3.49–40.55, P<0.001] and abnormal serum alanine aminotransferase level [≥1.25 × upper limit of normal (ULN) vs. <1.25 × ULN, OR 7.81, 95% CI 1.54–39.66, P=0.01]; HBV co‐infection was associated with abnormal serum aspartate aminotransferase level (OR 4.33, 95% CI 1.32–14.17, P=0.02).

Conclusions

These high rates of active HBV and HCV co‐infections in HIV‐positive Cameroonian patients requiring antiretroviral therapy underline the need to promote: (i) screening for HBV and HCV before treatment initiation; (ii) accessibility to tenofovir (especially in HBV‐endemic African countries); and (iii) accessibility to treatment for HBV and HCV infections.     

Absence of liver steatosis in HIV–HCV co-infected patients receiving regimens containing tenofovir or abacavir

Background

In human immunodeficiency virus–hepatitis C virus (HIV–HCV) co-infected patients, steatosis has been independently associated with a number of antiretroviral drugs, including stavudine, especially in patients with non-3 HCV genotypes. We retrospectively investigated the presence of steatosis among HIV–HCV co-infected and HCV mono-infected patients, and the role of tenofovir disoproxil fumarate (TDF) or abacavir (ABC) in determining hepatic steatosis.

Methods

Liver steatosis was retrospectively evaluated in all consecutive biopsies performed in the period 2000–2008 in HCV mono-infected and HIV–HCV co-infected patients. A steatosis rate of >5 % was considered to be significant, and a multivariate logistic analysis was performed to evaluate factors associated with steatosis.

Results

In total, 393 HCV-infected patients underwent liver biopsy during the study period, of whom 205 (52.2 %) were co-infected with HIV. A steatosis rate of >5 % was diagnosed in 33.0 % of HCV mono-infected and in 47.8 % of HIV–HCV co-infected patients (P = 0.003). The rate of steatosis was higher in patients resuming antiretroviral therapy (54.7 %) than in naïve patients (33.3 %; P = 0.006). When the overall population was considered, steatosis was associated to HCV genotype 3 [odds ratio (OR) 4.53, 95 % confidence interval (CI) 2.71–7.58; P < 0.001]. In terms of the use of nucleos(t)ide drugs in HIV co-infected patients, multivariate analysis showed that only in patients with HCV genotypes other than genotype 3 was steatosis related to the use of stavudine (OR 5.38, 95 % CI 1.18-24.53; P = 0.03). The use of TDF (OR 1.07, 95 % CI 0.39–2.88; P = 0.898) or ABC (OR 0.592, 95 % CI 0.09–4.07; P = 0.594) was not associated with steatosis.

Conclusion

In HCV mono-infected and HIV–HCV co-infected patients, steatosis appears to be a virus-mediated effect of HCV genotype 3. In HIV patients infected with HCV genotypes other than genotype 3, the risk of developing steatosis was higher in those patients resuming antiretroviral regimens containing old drugs rather than the new antiretrovirals.     

Effect of food on the antiviral activity of didanosine enteric-coated capsules: a pilot comparative study

Objectives

To determine the effect of food on the antiviral activity of enteric‐coated (EC) capsules of didanosine (ddI).

Methods

We conducted a pilot, randomized, open‐label study of 28‐day ddI‐EC capsules monotherapy‐administered in a fasted state (group 1, n=11) or with food (group 2, n=10) to treatment‐naïve chronically HIV‐1‐infected individuals. To assess the antiviral efficacy, HIV‐1 RNA was determined at baseline, day 3, day 7 and weekly thereafter. The area under the HIV‐1 RNA curve minus baseline weighted by time (AUCMB/day) was calculated.

Results

Mean baseline HIV‐1 RNA was 4.2 log₁₀ copies/mL in group 1 and 3.8 log₁₀ copies/mL in group 2. After 28 days, the mean HIV‐1 RNA reduction was 0.99 log₁₀ copies/mL [95% confidence interval (CI) 0.45–1.53] for group 1 and 0.89 log₁₀ copies/mL (95% CI 0.38–1.40) for group 2. AUCMB/day values were 0.775 log₁₀ copies/mL (95% CI 0.33–1.22) and 0.774 log₁₀ copies/mL (95% CI 0.48–1.07), respectively, showing no difference in the rate of decrease of HIV‐1 RNA (P=0.995). Mean ddI plasma levels at day 28 were 0.0234 mg/L for group 1 and 0.0227 mg/L for group 2 (P=0.96).

Conclusions

In this pilot study, the administration of food did not have any significant effect on the antiviral activity of ddI‐EC capsules.     

Risk factors for incident diabetes mellitus among HIV-infected patients receiving combination antiretroviral therapy in Taiwan: a case–control study

Objectives

Recent studies suggest that patients with HIV infection are at increased risk for incident diabetes mellitus (DM). We investigated the incidence and risk factors of DM among HIV‐infected patients receiving combination antiretroviral therapy (CART) in Taiwan.

Methods

Incident cases of DM were identified among HIV‐infected patients at the National Taiwan University Hospital between 1993 and 2006. A retrospective case–control study was conducted after matching cases with controls for sex, age at HIV diagnosis, year of HIV diagnosis, mode of HIV transmission and baseline CD4 lymphocyte count. A multivariate analysis was performed to identify risk factors for incident DM among HIV‐infected patients.

Results

In 824 HIV‐infected patients eligible for analysis, 50 cases of incident DM were diagnosed, resulting in an incidence of 13.1 cases per 1000 person‐years of follow‐up. In total, 100 matched controls were identified. Risk factors for incident DM were a family history of DM [odds ratio (OR) 2.656; 95% confidence interval (CI) 1.209–5.834], exposure to zidovudine (OR 3.168; 95% CI 1.159–8.661) and current use of protease inhibitors (OR 2.528; 95% CI 1.186–5.389).

Conclusions

Incident DM was associated with a family history of DM, exposure to zidovudine and current use of protease inhibitors in HIV‐infected patients receiving CART in Taiwan.     

Mother-to-child transmission of HIV-1: association with malaria prevention, anaemia and placental malaria

Objectives

Malaria infection may impact on mother‐to‐child transmission (MTCT) of HIV‐1. Prevention of malaria in pregnancy could thus potentially affect MTCT of HIV. We studied the impact of intermittent preventive treatment during pregnancy (IPTp) on HIV‐1 MTCT in southern Mozambique.

Methods

A total of 207 HIV‐positive Mozambican pregnant women were enrolled in the study as part of a randomized placebo‐controlled trial of two‐dose sulfadoxine‐pyrimethamine (SP) IPTp in women receiving single‐dose nevirapine to prevent MTCT of HIV. HIV RNA viral load, maternal anaemia and peripheral and placental malaria were assessed at delivery. Infant HIV status was determined by DNA polymerase chain reaction (PCR) at 1 month of age.

Results

There were 19 transmissions of HIV in 153 mother–infant pairs. IPTp with SP did not have a significant impact on MTCT (11.8% in the SP group vs. 13.2% in the placebo group; P=0.784) or on maternal HIV RNA viral load [16 312 (interquartile range {IQR} 4076–69 296) HIV‐1 RNA copies/mL in the SP group vs. 18 274 (IQR 5471–74 104) copies/mL in the placebo group; P=0.715]. In multivariate analysis, maternal HIV RNA viral load [adjusted odds ratio (AOR) 19.9; 95% confidence interval (CI) 2.3–172; P=0.006] and anaemia (haematocrit <33%; AOR 7.5; 95% CI 1.7–32.4; P=0.007) were independent risk factors for MTCT. Placental malaria was associated with a decrease in MTCT (AOR 0.23; 95% CI 0.06–0.89; P=0.034).

Conclusions

IPTp with SP was not associated with a significant impact on MTCT of HIV. Maternal anaemia was an independent risk factor for MTCT.     

History of viral suppression on combination antiretroviral therapy as a predictor of virological failure after a treatment change*

Objectives

HIV‐infected persons experience different patterns of viral suppression after initiating combination antiretroviral therapy (cART). The relationship between such differences and risk of virological failure after starting a new antiretroviral could help with patient monitoring strategies.

Methods

A total of 1827 patients on cART starting at least one new antiretroviral from 1 January 2000 while maintaining a suppressed viral load were included in the analysis. Poisson regression analysis identified factors predictive of virological failure after baseline in addition to traditional demographic variables. Baseline was defined as the date of starting new antiretrovirals.

Results

Four hundred and fifty‐one patients (24.7%) experienced virological failure, with an incidence rate (IR) of 7.3 per 100 person‐years of follow‐up (PYFU) [95% confidence interval (CI) 6.7–8.0]. After adjustment, patients who had rebounded in the year prior to baseline had a 2.4‐times higher rate of virological failure after baseline (95% CI 1.77–3.26; P<.0001), while there was no increased incidence in patients whose last viral rebound was >3 years prior to baseline [Incidence rate ratio (IRR) 1.06; 95% CI 0.75–1.50; P=0.73] compared with patients who had never virally rebounded. Patients had an 86% (95% CI 1.36–2.55; P<.0001), 53% (95% CI 1.06–2.04; P=0.02) and 5% (95% CI 0.80–1.38; P=0.72) higher virological failure rate after baseline if they were virally suppressed <50%, 50–70% and 70–90% of the time they were on cART prior to baseline, respectively, compared with those virally suppressed >90% of the time.

Discussion

Intensive monitoring after a treatment switch is required in patients who have rebounded recently or have a low percentage of time suppressed while on cART. Consideration should be given to increasing the provision of adherence counselling.     

Risk factors for HIV transmission among heterosexual discordant couples in South India*

Objective

To assess the risk factors associated with heterosexual HIV transmission among South Indian discordant couples enrolled in clinical care.

Methods

A nested matched case–control study of serodiscordant couples in which the HIV‐infected partner (index case) was enrolled in care. Demographic and clinical characteristics, sexual behaviours, CD4 cell count and plasma HIV‐1 RNA loads were measured at enrolment and longitudinally over 12 months of follow‐up. The study included 70 cases who seroconverted during study follow‐up and 167 matched controls who remained persistently serodiscordant.

Results

The incidence of HIV infection among the initially seronegative partners was 6.52 per 100 person‐years. Persistently discordant patients were more likely to have initiated highly active antiretroviral therapy (HAART) than patients in seroconverting relationships (62.9%vs. 42.9%) (P=0.001). Patients in seroconverting relationships had significantly higher plasma viral loads (PVLs) than patients in discordant relationships at enrolment, at 6 months and at 12 months (P<0.05). Patients in seroconverting relationships were less likely to use condoms with their primary partners than patients in discordant relationships (P<0.05). Patients in relationships that seroconverted between 6 and 12 months were diagnosed more often with genital Herpes simplex than patients in discordant relationships (P=0.001). In the univariate and multivariate logistic regression, the following variables were associated with seroconversion: PVL >100 000 [odds ratio (OR): 1.82; 95% confidence interval (CI): 1.1–2.8], non‐disclosure of HIV status (OR: 5.5; 95% CI: 4.3–6.2) and not using condoms (OR: 2.8; 95% CI: 2.4–3.6).

Conclusions

Couples‐based intervention models are crucial in preventing HIV transmission to seronegative spouses. Providing early treatment for sexually transmitted infections, HAART and enhancing condom use and disclosure could potentially decrease the risk of HIV transmission within Indian married couples.

     

Efavirenz replacement by immediate full-dose nevirapine is safe in HIV-1-infected patients in Cambodia

Background

Efavirenz is used for the antiretroviral treatment of HIV/tuberculosis‐coinfected patients in developing countries. A switch to nevirapine is regularly carried out because of the cost and side effects of efavirenz. Pharmacokinetic studies suggested that nevirapine should be initiated at full dose when used as a substitute for efavirenz.

Objectives

The aim of this study was to measure the cumulative incidence of adverse events (AEs) related to nevirapine in patients switched from efavirenz to immediate full‐dose nevirapine (FDN).

Methods

In 2001 an antiretroviral treatment programme was initiated with the first‐line regimen stavudine, lamivudine and efavirenz. In 2003, the fixed‐dose combination of stavudine, lamivudine and nevirapine was recommended. Thus, first‐line therapy was changed and FDN was initiated when patients were switched from efavirenz to nevirapine.

Results

Between April and December 2004, 394 patients were switched from efavirenz to FDN. The cumulative incidence of AEs related to nevirapine was 13.2% [95% confidence interval (CI) 10.2–16.7] and that of severe AEs was 8.9% (95% CI 6.5–11.9). In women the incidence of AEs was 17.6% (95% CI 12.1–24.3) and that of severe AEs was 12.2% (95% CI 7.7–18.2).

Conclusions

Our results indicate that an FDN switch from efavirenz does not appear to result in more AEs than when nevirapine is initiated with escalating doses. These data are particularly relevant in resource‐limited settings.     

Risks for methicillin‐resistant Staphylococcus aureus colonization or infection among patients with HIV infection*

Background

Risks for methicillin‐resistant Staphylococcus aureus (MRSA) among those with HIV infection have been found to vary, and the epidemiology of USA‐300 community‐acquired (CA) MRSA has not been adequately described.

Methods

We conducted a retrospective review of HIV‐infected out‐patients from January 2002 to December 2007 and employed multivariate logistic regression (MLR) to identify risks for MRSA colonization or infection. Pulsed‐field gel electrophoresis (PFGE) was used to identify USA‐300 strains. Results Seventy‐two (8%) of 900 HIV‐infected patients were colonized or infected with MRSA. MLR identified antibiotic exposure within the past year [odds ratio (OR) 3.4; 95% confidence interval (CI) 1.5–7.7] and nadir CD4 count <200 cells/μL (OR 2.5; 95% CI 1.2–5.3) as risks for MRSA colonization or infection. Receipt of antiretroviral therapy (ART) within the past year was associated with decreased risk (OR 0.16; 95% CI 0.07–0.4). Eighty‐nine percent of available strains were USA‐300. MLR identified skin or soft tissue infection (SSTI) as the only predictor for infection with USA‐300 (OR 5.9; 95% CI 1.4–24.3). Conclusion Significant risks for MRSA among HIV‐infected patients were CD4 count nadir <200 cells/μL and antibiotic exposure. Only the presence of an SSTI was associated with having USA‐300, and thus the use of patient characteristics to predict those with USA‐300 was limited. In addition, ART within the previous year significantly reduced the risk of MRSA colonization or infection.

     

Routine, voluntary HIV testing in Durban, South Africa: correlates of HIV infection

Background

Routine HIV testing is increasingly recommended in resource‐limited settings. Our objective was to evaluate factors associated with a new diagnosis of HIV infection in a routine HIV testing programme in South Africa.

Methods

We established a routine HIV testing programme in an out‐patient department in Durban, South Africa. All registered adults were offered a rapid HIV test; we surveyed a sample of tested patients.

Results

During the 12‐week study, 1414 adults accepted HIV testing. Of those, 463 (32.7%) were HIV‐infected. Seven hundred and twenty (50.9%) were surveyed. Compared with married women, unmarried men were at the highest risk of HIV [odds ratio (OR) 6.84; 95% confidence interval (CI) 3.45–23.55], followed by unmarried women (OR 5.90; 95% CI 3.25–10.70) and married men (OR 4.00; 95% CI 2.04–7.83). Age 30–39 years (compared with ≥50 years; OR 5.10; 95% CI 2.86–9.09), no prior HIV test (OR 1.45; 95% CI 1.07–2.27) and an imperfect HIV knowledge score (OR 2.32; 95% CI 1.24–4.35) were also associated with HIV infection.

Conclusion

In a routine HIV testing programme in South Africa, rates of previously undiagnosed HIV were highest among men, young and unmarried patients, and those with poorer HIV knowledge. Better interventions are needed to improve HIV knowledge and decrease HIV risk behaviour.