Chokechai Rongkavilit

Experience with caspofungin in the treatment of persistent fungemia in neonates

OBJECTIVE:To review our experience of caspofungin in the treatment of persistent candidemia in the neonatal intensive care unit.STUDY DESIGN:This was a retrospective chart review on 13 infants in whom caspofungin was added to conventional antifungals (amphotericin B and/or fluconazole or flucytosine) for the treatment of refractory candidemia.RESULTS:A total of 12 infants were preterm (gestational age, 24 to 28 weeks) and one was term; the median birth weight was 800 g (range, 530 to 5600 g). Candidemia (Candida albicans in five, C. parapsilosis in six, C. albicans and C. parapsilosis in one and C. tropicalis in one) persisted despite 6 to 30 days of conventional antifungal therapy. After the addition of caspofungin, sterilization of blood cultures was achieved in 11 infants at the median time of 3 days (range, 1 to 21 days). Adverse events included thrombophlebitis (one patient), hypokalemia (two patients) and elevation of liver enzymes (four patients). Three infants had a second episode of candidemia and seven patients died.CONCLUSION:Caspofungin may be an efficacious addition for treatment of candidemia refractory to conventional antifungal therapy. This drug should be further investigated in neonates.

HIV stigma, disclosure and psychosocial distress among Thai youth living with HIV.

The objective of the present paper is to assess stigma and to create an abbreviated 12-item Stigma Scale based on the 40-item Bergers Stigma Scale for Thai youth living with HIV (TYLH). TYLH aged 16–25 years answered the 40-item Stigma Scale and the questionnaires on mental health, social support, quality of life and alcohol/substance use. Sixty-two (88.6%) of 70 TYLH reported at least one person knowing their serostatus. Men having sex with men were more likely to disclose the diagnosis to friends (43.9% versus 6.1%, P < 0.01) and less likely to disclose to families (47.6% versus 91.8%, P < 0.01). Women were more likely to disclose to families (90.2% versus 62.1%, P < 0.01) and less likely to disclose to friends (7.3% versus 31%, P < 0.05). The 12-item Stigma Scale was reliable (Cronbachs α, 0.75) and highly correlated with the 40-item scale (r = 0.846, P < 0.01). Half of TYLH had mental health problems. The 12-item Stigma Scale score was significantly associated with mental health problems (β = 0.21, P < 0.05). Public attitudes towards HIV were associated with poorer quality of life (β = −1.41, P < 0.01) and mental health problems (β = 1.18, P < 0.01). In conclusion, the12-item Stigma Scale was reliable for TYLH. Increasing public understanding and education could reduce stigma and improve mental health and quality of life in TYLH.

Thai Red Cross zidovudine donation program to prevent vertical transmission of HIV: The effect of the modified ACTG 076 regimen

ObjectivesTo evaluate the impact of the modified ACTG 076 zidovudine regimen on the risk for vertical HIV transmission. DesignObservational retrospective evaluation of a prospective cohort. SettingThai Red Cross zidovudine donation program to reduce vertical HIV transmission. PatientsHIV-infected Thai women and their offspring. InterventionThe modified regimen consisted of 500 mg zidovudine daily during pregnancy and 300 mg zidovudine every 3 h during labor, taken orally, and 2 mg/kg zidovudine syrup four times daily for 6 weeks to infants. Main outcome measuresOnly infants with at least 1 HIV DNA polymerase chain reaction (PCR) result at age ⩾ 4 weeks were included. HIV infection was defined by having at least one positive PCR at age ⩾ 4 weeks. The transmission rate was calculated. Characteristics of women who did and did not transmit HIV to infants were compared. ResultsA total of 2891 women and their infants participated in the program and 726 infants of 719 women were included in the analysis. Forty-three infants were infected. The overall transmission rate was 6.0% (95% confidence interval, 4.4–8.0). There were no differences in maternal characteristics between transmitters and non-transmitters. The transmission rate in women who started zidovudine before 30 weeks’ gestation was not significantly different from that in women who started zidovudine at or after 30 weeks’ gestation: 5.7 versus 3.3%, respectively. ConclusionsThis modified zidovudine regimen is effective in reducing vertical transmission in a country with predominant subtype E infection. A donation program for preventing vertical HIV transmission can be implemented in developing countries, as in Thailand.

Use of complementary and alternative medicine by parents of children with HIV infection and asthma and well children.

Objective: Although the use of complementary and alternative medicine (CAM) in children is increasing, little is known about its use in children with human immunodeficiency virus (HIV) infection. This study investigated the use of CAM by parents of children with HIV infection (H), children with asthma (A), and well children (W). Our hypothesis was that parents of the H group are more likely to use CAM than parents of the W or A group because of the nature and severity of the illness. Materials and Methods: Parents of 152 subjects [H (n = 46), A (n = 53), and W (n = 53)] were interviewed on the use of CAM for their children, types of CAM, reasons for use/nonuse, methods of payment, and perceived benefits for their children. Results: Compared with parents of the W and A groups, parents of the H group were less likely to be employed, were less likely to have private insurance, were less likely to have a high school or college education, and were more likely to be black. Interestingly, 38% of the W parents used CAM in their children compared with 22% in the H group and 25% in the A group. More than 80% of all three groups paid out of pocket for their use of CAM in their children. Within these groups, H parents were more likely to want CAM as part of their child’s medical care (H = 91% vs W = 75% and A = 67%, P = 0.02) and were more likely to believe that CAM was expensive (H = 78% vs W = 57% and A = 60%, P < 0.01). Conclusions: Our study revealed a relatively high rate of CAM usage by parents of all three study groups. Although parents of children with HIV infection were more likely to want CAM as part of their children’s medical care, their rate of CAM usage was not higher than that in well children. This may be related to their socioeconomic factors. A larger and more diverse study population may provide more information on factors contributing to CAM usage in chronically ill and well children.

Pharmacokinetics of Stavudine and Didanosine Coadministered with Nelfinavir in Human Immunodeficiency Virus-Exposed Neonates

ABSTRACT We evaluated the pharmacokinetics of stavudine (d4T) and didanosine (ddI) in neonates. Eight neonates born to human immunodeficiency virus-infected mothers were enrolled to receive 1 mg of d4T per kg of body weight twice daily and 100 mg of ddI per m2 once daily in combination with nelfinavir for 4 weeks after birth. Pharmacokinetic evaluations were performed at 14 and 28 days of age. For d4T, on days 14 and 28, the median areas under the concentration-time curves from 0 to 12 h (AUC0–12s) were 1,866 and 1,603, ng · h/ml, respectively, and the median peak concentrations (Cmaxs) were 463 and 507 ng/ml, respectively. For ddI, on days 14 and 28, the median AUC0–10s were 1,573 and 1,562 h · ng/ml, respectively, and the median Cmaxs were 627 and 687 ng/ml, respectively. Systemic levels of exposure to d4T were comparable to those seen in children, suggesting that the pediatric dose of 1 mg/kg twice daily is appropriate for neonates at 2 to 4 weeks of age. Levels of exposure to ddI were modestly higher than those seen in children. Whether this observation warrants a reduction of the ddI dose in neonates is unclear.

Transtheoretical model and risky sexual behaviour in HIV + youth in Thailand

Abstract The purpose of the study was to determine the applicability of the Transtheoretical Model for predicting unprotected intercourse in HIV+ Thai youth. Questionnaires and interviews about sexual behaviour, readiness to change, self-efficacy, substance use, emotional distress and social support were obtained from 70 HIV+ Thai youth (ages 17 to 25). Path analysis suggested the model was an excellent fit with the data. Readiness to change but not self-efficacy was directly related to unprotected intercourse acts. This differed from HIV+ youth in the US where self-efficacy fully mediated the relationship between readiness to change and condom use. In the Thai sample, social support and self-efficacy were indirectly related to unprotected intercourse through stage of change. Substance use was unrelated to unprotected intercourse, but rates of use were low. Potential cultural differences in the construct of self-efficacy and its relationship to risky behaviours in Thailand require further study. However, results highlight the potential of prevention interventions that increase readiness to change through boosting self-efficacy and social support specific to practicing safer sex while addressing mental health concerns.

A feasibility study of motivational interviewing for health risk behaviors among thai youth living with HIV

hailandisamongthefewless-developedcountrieswith successful HIV prevention among segments ofthe population (National AIDS Prevention andAlleviation Committee, 2010). However, the successof HIV prevention among Thai adolescents andyoung adults has been questionable. The highestpercentage of Thai persons with AIDS remain inthe age group of 25–34 years, indicating that thetime of greatest HIV acquisition has occurred inadolescence and young adulthood (Thai WorkingGroup on HIV/AIDS, 2010). Most Thai youth livingwith HIV (TYLH) acquire HIV through sexualcontact (National AIDS Prevention and AlleviationCommittee, 2010). In a study of TYLH, only half re-ported consistent condom use in the previous 30 days(Rongkavilit et al., 2007); therefore, secondaryprevention targeting sexual risk behaviors in TYLHare needed.Behavioral intervention research targeting youthwith HIV in less-developed countries remains non-existent. An intervention that is brief, culturallyacceptable, and can increase young people’s intrinsicmotivation to reduce risk behaviors and maintainthese changes over time is critically neededfor this setting. Motivational interviewing (MI),an empirically supported behavioral counselingapproach, targets an individual’s intrinsic motivationfor change by exploring and resolving ambivalenceabout behavior change while supporting theindividual’s self-efficacy and autonomy for makingchanges. The MI approach can impact the informa-tion, motivation, and behavioral skills necessary toachieve a behavior change according to theInformation-Motivation-Behavioral Skills model(Fisher & Fisher, 1992). MI has been successfully

A Cross-Cultural Three-Step Process Model for Assessing Motivational Interviewing Treatment Fidelity in Thailand

The provision of culturally relevant yet evidence-based interventions has become crucial to global HIV prevention and treatment efforts. In Thailand, where treatment for HIV has become widely available, medication adherence and risk behaviors remain an issue for Thai youth living with HIV. Previous research on motivational interviewing (MI) has proven effective in promoting medication adherence and HIV risk reduction in the United States. However, to test the efficacy of MI in the Thai context a feasible method for monitoring treatment fidelity must be implemented. This article describes a collaborative three-step process model for implementing the MI Treatment Integrity (MITI) across cultures while identifying linguistic issues that the English-originated MITI was not designed to detect as part of a larger intervention for Thai youth living with HIV. Step 1 describes the training of the Thai MITI coder, Step 2 describes identifying cultural and linguistic issues unique to the Thai context, and Step 3 describes an MITI booster training and incorporation of the MITI feedback into supervision and team discussion. Throughout the process the research team collaborated to implement the MITI while creating additional ways to evaluate in-session processes that the MITI is not designed to detect. The feasibility of using the MITI as a measure of treatment fidelity for MI delivered in the Thai linguistic and cultural context is discussed.

Herpes simplex virus type 1 esophagitis in an immunocompetent adolescent

Esophagitis caused by herpes simplex virus (HSV) has been well described in immunocompromised or severely ill hosts. HSV esophagitis may occasionally occur as an acute, self-limited illness in immunocompetent patients (1–8). Acyclovir therapy has been used in few immunocompetent pediatric patients with HSV esophagitis. (6, 7). However, its efficacy in this setting is currently unknown. We herein present an immunocompetent adolescent with HSV esophagitis who had a dramatic response to acyclovir therapy.

Advances in Prevention of Mother-to-Child HIV Transmission: The International Perspectives

We have sufficient knowledge and unprecedented access to global resources to dramatically reduce the transmission of HIV-1 from mother to children worldwide. Most transmission occurs during delivery and after birth through breastfeeding. For this reason, efforts to interrupt transmission have focused on peripartum period and safe infant feeding. This includes the use of antiretroviral therapy, elective cesarean section, avoidance of breastfeeding, and exclusive breastfeeding. This review summarizes recent studies and new international development on the prevention of mother-to-child HIV transmission. Prevention of mother-to-child transmission of HIV should now be integrated as part of basic maternal and child health services.