Natasha Press

Intermittent use of triple-combination therapy is predictive of mortality at baseline and after 1 year of follow-up.

Objective To characterize the impact of intermittent use of triple drug antiretroviral therapy on survival. Design, setting and participants Population-based analysis of 1282 antiretroviral therapy naive HIV-positive individuals aged 18 years and older in British Columbia who started triple-combination therapy between August 1996 and December 1999. Therapy use was estimated by dividing the number of months of medications dispensed by the number of months of follow-up. Intermittent therapy was defined as the participant having obtained less than 75% of their medication in the first 12 months. Main outcome measure Cumulative all-cause mortality rates from the start of triple drug antiretroviral therapy to 30 September 2000. Results As of 30 September 2000, 106 subjects had died. Cumulative mortality was 3.9% (± 0.5%) at 12 months. In a multivariate model, after controlling for other variables that were significant in the univariate analyses each 100 cell decrement in baseline CD4 cell count and the intermittent use of antiretroviral drugs were associated with increased mortality with risk ratios of 1.31 [95% confidence interval (CI), 1.16–1.49;P < 0.001] and 2.90 (95% CI, 1.93–4.36;P < 0.001), respectively. In order to control for downward drift, intermittent use of therapy was measured over the first year whereas other factors were measured at the end of year 1. After adjusting for all other factors, those participants who used antiretroviral drugs intermittently were 2.97 times (95% CI, 1.33–6.62;P = 0.008) more likely to die. Conclusion Our study demonstrates that even after adjusting for other prognostic factors intermittent use of antiretroviral therapy was associated with increased mortality.

Risk of Anal Cancer in HIV-Infected and HIV-Uninfected Individuals in North America

BACKGROUNDnAnal cancer is one of the most common cancers affecting individuals infected with human immunodeficiency virus (HIV), although few have evaluated rates separately for men who have sex with men (MSM), other men, and women. There are also conflicting data regarding calendar trends.nnnMETHODSnIn a study involving 13 cohorts from North America with follow-up between 1996 and 2007, we compared anal cancer incidence rates among 34u2009189 HIV-infected (55% MSM, 19% other men, 26% women) and 114u2009260 HIV-uninfected individuals (90% men).nnnRESULTSnAmong men, the unadjusted anal cancer incidence rates per 100u2009000 person-years were 131 for HIV-infected MSM, 46 for other HIV-infected men, and 2 for HIV-uninfected men, corresponding to demographically adjusted rate ratios (RRs) of 80.3 (95% confidence interval [CI], 42.7-151.1) for HIV-infected MSM and 26.7 (95% CI, 11.5-61.7) for other HIV-infected men compared with HIV-uninfected men. HIV-infected women had an anal cancer rate of 30/100u2009000 person-years, and no cases were observed for HIV-uninfected women. In a multivariable Poisson regression model, among HIV-infected individuals, the risk was higher for MSM compared with other men (RR, 3.3; 95% CI, 1.8-6.0), but no difference was observed comparing women with other men (RR, 1.0; 95% CI, 0.5-2.2). In comparison with the period 2000-2003, HIV-infected individuals had an adjusted RR of 0.5 (95% CI, .3-.9) in 1996-1999 and 0.9 (95% CI, .6-1.2) in 2004-2007.nnnCONCLUSIONSnAnal cancer rates were substantially higher for HIV-infected MSM, other men, and women compared with HIV-uninfected individuals, suggesting a need for universal prevention efforts. Rates increased after the early antiretroviral therapy era and then plateaued.

Virologic and immunologic response, clinical progression, and highly active antiretroviral therapy adherence.

Summary: A growing body of evidence suggests that a high degree of adherence is required to achieve and maintain a successful virologic response both in the short and long term. This holds true despite the definition of adherence or how it is measured. Reported differences in the degree of adherence required are likely due to differences in study design, difficulty measuring patient adherence, patient population studied, and the antiretroviral regimen studied. Virologic suppression and immunologic response often go hand in hand, but the impact of adherence on change in CD4 count tends to be delayed and, therefore, less apparent than the impact on HIV viral load. Degree of adherence has also been shown to be associated with AIDS‐related morbidity, mortality, and hospitalizations.

HAART slows progression to anal cancer in HIV-infected MSM.

Objective:Antiretrovirals do not prevent anal intraepithelial neoplasia. However, the influence of antiretrovirals in the natural history of invasive anal cancer is less clear. The objective is to investigate the impact of antiretrovirals in the time to the development of anal cancer in HIV-positive MSM. Design:A retrospective analysis of cases of anal cancer in a cohort of HIV-positive MSM receiving antiretrovirals between 1988 and 2008. Methods:Time from first CD4+ cell count or HIV RNA viral load test to anal cancer diagnosis was analysed using Cox regression and Kaplan–Meier curves. Anal cancer cases treated in the era prior to HAART (<1996) were compared with those treated later (1996–2008). Results:Anal cancer cases (nu200a=u200a37) were compared with a cohort of 1654 HIV-positive MSM on antiretrovirals. Antiretrovirals were started in the pre-HAART era by 70% of cancer cases, and median CD4+ cell count nadir was 70u200acells/&mgr;l (10–130). Time to development of anal cancer was shorter for cases treated during the pre-HAART era [adjusted hazard ratio (AHR) 3.04, 95% confidence interval (95% CI) 1.48–6.24, Pu200a=u200a0.002], with a CD4+ cell count nadir less than 100u200acells/&mgr;l (AHR 2.21, 95% CI 1.06–4.62, Pu200a=u200a0.035) and longer duration of CD4+ cell count less than 100u200acells/&mgr;l (AHR 1.33, 95% CI 1.11–1.58, Pu200a=u200a0.002). Conclusion:Results show that severe immunosuppression and starting therapy pre-HAART are associated with an increased risk of anal cancer. HIV-positive MSM initiating antiretrovirals during the HAART era (1996–2008) had a longer time to the development of anal cancer than those treated pre-HAART. Our results suggest that early use of HAART may delay progression to anal cancer.

Screening for sexually transmitted diseases in human immunodeficiency virus-positive patients in Peru reveals an absence of Chlamydia trachomatis and identifies Trichomonas vaginalis in pharyngeal specimens

To determine the prevalence of sexually transmitted diseases (STDs), we screened 107 human immunodeficiency virus-positive patients in Peru, where the virus is predominantly sexually transmitted. Patients had multiple risk factors for STDs, and 38% of women and 50% of men had at least 1 STD (gonorrhea, trichomoniasis, herpes simplex, anogenital warts, or syphilis seropositivity). No chlamydial infection was detected, even though infection rates in the general population are 5%-12%. Patients receiving trimethoprim-sulfamethoxazole(TMP-SMZ) for prophylaxis or treatment of respiratory infections were least likely to have cervicitis and/or urethritis (odds ratio, 0.37; 95% confidence interval, 0.15-0.89). Although not optimal treatment, administration of TMP-SMZ is effective against chlamydial infection. We speculate that the use of concomitant medications, such as TMP-SMZ, may be inadvertently preventing chlamydial infection in this population. Another finding was the presence of Trichomonas vaginalis in pharyngeal specimens of 3 men with histories of orogenital activity. This has not been previously reported and requires further study.

Feasibility of Incorporating Self-Collected Rectal Swabs Into a Community Venue-Based Survey to Measure the Prevalence of HPV Infection in Men Who Have Sex With Men

Background: Inclusion of self-collected rectal swabs (SCRS) into existing community venue-based HIV surveillance systems for men who have sex with men (MSM) may provide a feasible method for monitoring human papillomavirus (HPV) vaccine-related outcomes in this population. We measured the prevalence of HPV and anal dysplasia through incorporating SCRS into ManCount, the Vancouver site of the M-Track HIV surveillance system. Methods: Participating MSM were provided with a self-collection kit for collection on-site or at a follow-up venue. Swabs were subject to polymerase chain reaction amplification for HPV detection, and cytology slides were reviewed for anal dysplasia. Factors associated with participation were identified through multivariate logistic regression. Results: Of 766 men completing ManCount, 268 (35%) agreed to participate, self-collecting 252 specimens (247 on-site). Of 239 complete specimens, 33.5% did not have detectable &bgr;-globin; in the remainder (159 specimens) the prevalence of HPV infection was 62.3% (23.3% HPV type 16 or 18; 38.4% HPV type 6, 11, 16, or 18). In the 62.3% (149) of specimens adequate for cytology, the prevalence of anal dysplasia was 42.3% (HSIL 11.4%, LSIL 18.8%, ASC-US 6.7%, ASC-H 5.4%). Participation was associated with venue type, availability of on-site collection, and other characteristics. Conclusions: SCRS can be feasibly integrated within existing community venue-based HIV surveillance systems for MSM, and may be a suitable method for monitoring the impact of HPV vaccination in this population. However, participation may be influenced by venue type and availability of on-site collection, and adequacy of SCRS specimens may be lower in community venues as compared with clinical settings.

Prevalence of sexually transmitted infections and high-risk sexual behaviors in heterosexual couples attending sexually transmitted disease clinics in Peru.

Objectives: The objectives of this study were to determine the prevalence of sexually transmitted infection (STIs) in heterosexual couples and the sexual behaviors associated with their acquisition. Goal: The goal of this study was to better direct educational efforts to decrease STI among heterosexual couples in Lima, Peru. Study Design: We conducted a case-control study in 195 heterosexual couples without HIV infection who attended 2 sexually transmitted disease clinics in Lima, Peru. A case was defined as an individual with one or more newly diagnosed STIs such as gonorrhea, chlamydia, trichomoniasis, herpes simplex, syphilis, mycoplasma, or ureaplasma. Results: Thirty-three percent of individuals (41 men and 89 women) had at least one STI and 26 couples (13%) had the same STI detected. Men who have sex with men (MSM) accounted for 13% of all men, had higher rate of STIs and higher risk behaviors than non-MSM. Ureaplasma infection was the most prevalent STI found in both men and women and was associated with oral sexual contact. In heterosexual pairs, condom use during anal sex occurred less than 10% of the time. Conclusions: The heterosexual couples in sexually transmitted disease clinics have high-risk behaviors and STIs are frequent. The educational effort concerning prevention of STIs requires higher effort.

Colorectal and anal cancer in HIV/AIDS patients: a comprehensive review

Highly active antiretroviral therapy (HAART) has significantly altered the epidemiology of cancer that is diagnosed in individuals who are infected with the human immunodeficiency virus (HIV). Studies have shown a dramatic decrease in the incidence of and mortality from AIDS-related malignancies (primarily Kaposi sarcoma and non-Hodgkins lymphoma), while the incidence of and mortality from non-AIDS defining malignancies is on the rise. While the risk of colorectal cancer (CRC) in HIV-infected individuals is controversial and has received limited study, there has been accumulating evidence that suggests an increased risk of developing anal cancer (AC) during the HAART era. This article reviews the current literature reporting on CRC and AC in the HIV-infected population, with a specific on cancer: incidence, screening, clinical characteristics, and treatment outcomes.

A cluster of Bacillus cereus bacteremia cases among injection drug users

Bacillus cereus is a bacteria commonly found in nature that is most frequently implicated as the cause of gastrointestinal illness caused by ingestion of contaminated food; however, there are also reports of extraintestinal infections, although rare. This article describes three cases in which B cereus bacteremia occurred among injection drug users living in Vancouver, British Columbia, within a short period of time. Pulsed-field gel electrophoresis was performed to determine whether these three isolates were related.

RESOLUTION OF DIABETES AFTER INITIATION OF ANTIRETROVIRAL THERAPY IN TWO HUMAN IMMUNODEFICIENCY VIRUS-INFECTED PATIENTS

OBJECTIVEnTo describe two cases of human immunodeficiency virus (HIV)-infected patients who had diabetes mellitus, which resolved after initiation of antiretroviral therapy.nnnMETHODSnWe present the clinical and laboratory findings and describe the clinical course of these two patients.nnnRESULTSnA 48-year-old HIV-infected black woman presented with multiple infections and hyperglycemia. After her acute infections were treated and she was feeling well, she continued to have diabetes that necessitated insulin therapy. Administration of a protease inhibitor-based antiretroviral regimen resolved her diabetes and eliminated the need for insulin or oral therapy. Our second patient, a 37-year-old HIV-infected black man, presented with polyuria and polydipsia and a hemoglobin A1c value of 11%. He received antiretroviral therapy, and his diabetes resolved after a period of 2 1/2 months.nnnCONCLUSIONnProtease inhibitor-based antiretroviral therapy is associated with diabetes mellitus in up to 6% of HIV-infected patients. Although most HIV-infected patients in whom diabetes develops have this disorder after initiation of protease inhibitor therapy, the current two cases illustrate patients in whom diabetes resolved after use of antiretroviral therapy. This finding supports the presence of other mechanisms that affect glucose metabolism in patients infected with HIV and suggests that control of HIV infection may have a role in controlling diabetes.