Somsong Teeratakulpisarn

A randomized, dose-finding study with didanosine plus stavudine versus didanosine alone in antiviral-naive, HIV-infected Thai patients.

ObjectivesTo evaluate the safety and efficacy of four different regimens of didanosine (ddI) + stavudine (d4T) in HIV-infected Thais. DesignProspective, open-label, randomized study. MethodsPatients were randomized to four regimens of high and low doses of ddI and d4T or to ddI alone. D4T was added to the ddI-alone arm after week 24. The duration of study was 48 weeks. ResultsSeventy-eight patients were randomized (mean CD4 cell count, 255 × 106/l; mean plasma HIV-1 RNA; 4.3 log10 copies/ml). In the intent-to-treat analysis, 78% of patients in the pooled combination arms and 20% of the patients in the ddI alone arm (to which d4T was added after 24 weeks) showed plasma HIV-1 RNA < 500 copies/ml at week 24 (P  < 0.001), and 59% versus 53% at week 48, respectively. In addition, the proportion of patients with < 50 HIV-1 RNA copies/ml was 13% versus 7% at week 24 (P  = 0.5) and 17% versus 20% at week 48 respectively. At week 24, median CD4 cell count increases from baseline were 101 × 106/l in the pooled combination versus 76 × 106/l in the ddI alone arm (P  = 0.78). Logistic regression modeling suggested a correlation between receiving high dose ddI and achieving HIV-1 RNA < 500 copies/ml at week 48 (P  = 0.07). ConclusionsThe d4T/ddI combination was superior to ddI alone in producing HIV-1 viral suppression. At week 48, > 60% of patients treated with this combination reached HIV-1 RNA levels < 500 copies/ml. Receiving high dose ddI but not d4T may correlate with a better viral suppression.

Acceptability of male circumcision for the prevention of HIV among high-risk heterosexual men in Thailand.

Limited data are available on circumcision prevalence and acceptability among Thai men to prevent human immunodeficiency virus. Of 408 high-risk heterosexual men, 12.3% were circumcised. 14.2% and 24.9% expressed willingness to be circumcised before and after circumcision education, respectively. Neonatal circumcision acceptability was relatively high. One participant underwent circumcision at 3-month follow-up.

Creation of a drug fund for post-clinical trial access to antiretrovirals

The long running debate about clinical trial sponsors’ responsibility for providing treatment to patients after a trial has ended does not seem likely to end soon. In September 2003 the World Medical Association postponed its decision about whether or not the Declaration of Helsinki should be revised to reflect concerns that the US government and the pharmaceutical industry have expressed about post-trial treatment. Paragraph 30 of the Declaration of Helsinki currently states: “At the conclusion of the study every patient entered into the study should be assured of access to the best proven prophylactic diagnostic and therapeutic methods identified by the study”. The proposed revision to paragraph 30 would introduce two main changes: that the physician should make every effort to see that patients receive treatment once it has been approved by appropriate authorities and that the physician is required to explicitly tell patients if they are unlikely to continue receiving treatment from sponsors after they leave the study. The ethical concerns over the undertaking of clinical trials in developing countries especially with respect to the standard of treatment that should be provided to trial participants have resulted in little research in countries where interventions are needed most. The initiation of preventative HIV vaccine trials has been delayed by debate about the provision of antiretrovirals to participants. (excerpt)

AIDS at a university hospital in Bangkok, Thailand.

Approximately 800000 people in Thailand are infected with HIV with 1.3-1.8 million projected to be infected by 2005. A cumulative total of 19602 AIDS cases had been reported to the AIDS register of the Thai Ministry of Public Health by the end of 1994. The authors systematically studied all 446 consecutive patients attending the Chulalongkorn University Hospitals (CUH) Immune Clinic during a two-month period in early 1994. The CUH is a modern 1200-bed facility in Bangkok. The number of adult patients with HIV and AIDS attending the hospitals Immune Clinic outpatient services steadily increased from fewer than 10 per week in 1988 to approximately 200 per week in early 1994. Patients were examined for their current symptoms of HIV disease and their patient records screened for demographic risk factor laboratory and clinical data. The subjects were of mean age 31.7 years of range 18-70 years 79% male and 82% infected through heterosexual contact 8% through bisexual and homosexual contact and 4% through IV drug use. Oral hairy leukoplakia pruritic papular eruption oral candidiasis and herpes zoster were the leading manifestations in the clinical stage B patients. Among 124 cases with an AIDS-defining illness tuberculosis (TB) was the most common complication among 69. Pneumocystis carinii pneumonia (PCP) and cryptococcal meningitis were found in 11 and 13 patients respectively. Study findings together with the analysis of mortality on the medical wards by the end of 1994 determined TB to be the major complication among Thai patients with AIDS as well as the leading cause of hospitalization and death. An appropriate prophylactic regimen against TB is being investigated at the CUH.

Attitudes toward, and interest in, the test-and-treat strategy for HIV prevention among Thai men who have sex with men

This study assessed the attitudes toward, and interest in, the test-and-treat strategy, comprising regular HIV testing and immediate antiretroviral treatment (ART) among men who have sex with men (MSM) in Bangkok, Thailand. A total of 363 participants completed the questionnaires before and after learning about their HIV status. Previous HIV testing reported by 69.8% and 34.7% tested at least annually. Before pretest counseling, 83.2% expressed interest in regular HIV testing and 78.8% in immediate ART. MSM who tested HIV-positive at enrollment were less likely than those who tested HIV-negative to have been tested for HIV before (45.7% vs. 60.8%, p < 0.0001). Among MSM who tested HIV-positive (n = 69, 15.9%), the median level of willingness to take ART immediately increased significantly after learning about their positive results (90 vs.100%, p < 0.0001). Interest in regular HIV testing remained high among HIV-negative MSM after becoming aware of their status (70.9% before vs. 71.9% after, p = 0.55). MSM participants have a strong desire and willingness to start ART immediately upon receiving an HIV-positive test result; it is important to provide the necessary information on the health benefits of early ART and education to the community to maintain their health and prevent HIV transmission.

In vivo cell-mediated immunity in subjects with undetectable viral load on protease inhibitor-based versus non-protease inhibitor-based highly active antiretroviral therapy.

To the Editor: Delayed hypersensitivity skin testing (DTH) is a widely available, cost-effective, and relatively easy-to-use tool for detection of cell-mediated immunity (CMI). A response to DTH signifies intact CMI, whereas a negative response may represent a possible defect in CMI or a lack of previous exposure. In HIV infection, DTH predicts clinical progression (1,2) and has been shown to correlate with CD4 cell count (1,3). Highly active antiretroviral therapy (HAART) has significantly improved clinical progression of HIV infection (4,5). HAART with protease inhibitors (PIs) has also rapidly restored immunologic abnormalities in HIV infection (6,7). Although studies have shown the virologic efficacy of non-PI HAART (8–10), data on the recovery of immunologic functions with these regimens is scarce. Indeed, it has been postulated by some that PI-based regimens may result in better immune reconstitution compared with regimens without PIs. In this prospective, nonrandomized, cross-sectional study, HIV-infected subjects with and without HAART were recruited between August 1 and September 30, 2001. Recruitment was done at the Thai Red Cross AIDS Research Center and the Immune Clinic at Chulalongkorn Hospital in Bangkok, Thailand. Inclusion criteria for subjects on HAART were viral load (VL) <50 copies/mL for at least 6 months and maintenance on one of these regimens: triple nucleoside reverse transcriptase inhibitor (NRTI), dual NRTI plus nonnucleoside reverse transcriptase inhibitor (NNRTI), or dual NRTI plus PIs during the period of viral suppression. HIV-infected untreated subjects served as controls. The most recent CD4 cell count within 6 months of the recruitment date was used. The multitest CMI (11) used in this study includes the following antigens: Candida, Trichophyton, Proteus mirabilis, old tuberculin, Streptococcus group C, diphtheria, and tetanus (MULTITEST CMI; Aventis Pasteur Thailand, Ltd, Thailand). The DTH was placed by trained personnel and read at 48 to 72 hours after placement by 2 immunologists. The average of combined horizontal and vertical diameters in millimeters represented the DTH response to each antigen. Subjects with response of 5 mm to tuberculin were advised to obtain chest radiography (CXR). Subjects with normal CXR were advised to take isoniazid for 9 months, whereas subjects with abnormal CXR were advised to visit their physician for further investigation for tuberculosis. The primary outcome was the summed DTH response, defined as the summation of induration in millimeters to each antigen divided by the number of antigens with induration. Furthermore, the percentage of subjects with intact CMI, defined as a positive DTH response ( 2 mm) to at least two antigens, and the ability of individual antigens to elicit a DTH response were investigated. For the groups of subjects compared (PI-HAART, non-PI–HAART, HAART-treated, and HAART-untreated), stratified analysis was performed based on a CD4 count of <350 or 350 cells/mm, according to the current recommendation for the initiation of HAART (12). Differences between groups were calculated using the Mann-Whitney U test at an value of 0.05. For three-group comparison, the Kruskal-Wallis H test was performed. Multiple linear regression was used to determine factors related to DTH response. A total of 142 subjects underwent DTH. Ninety-three subjects were treated with HAART, and 49 were untreated. Subjects on HAART were divided into a group of PI-HAART (n 22) and a group of non-PI–HAART (n 71; 10 triple NRTI and 61 dual NRTI plus NNRTI). There were significant differences between HAART-untreated and HAART-treated groups in age (younger in untreated group, 33.2 ± 7.9 years versus 38.1 ± 5.4 years in treated group; p < .01) and median CD4 cell count (lower in the <350 cells/mm strata for untreated subjects, 149 (53–225) versus 242 (176–291) for treated subjects; p < .002). Between the HAART-treated groups, baseline differences were Centers for Disease Control and Prevention (CDC) clinical class (more subjects in CDC class A for nonPI–HAART, 55.1% versus 22.7% for PI-HAART; p < .001) and time on HAART (longer for patients with PIs, 2.41 ± 0.7 years versus 1.67 ± 0.92 years without PIs; p < .01). Otherwise, the groups were well balanced. Table 1 demonstrates the summed DTH response and the percentages of subjects with intact CMI and with a positive old tuberculin test according to HAART status, CD4 categories, and treatment regimens. Overall, there was no statistically significant difference between the summed DTH response in subjects on HAART with and without PIs. This also applied when subjects were stratified within the <350 cells/mm and 350 cells/mm groups. The percentage of subjects with intact CMI was higher in the non-PI group, however. When comparing subjects on HAART with subjects without HAART, summed DTH response was significantly better in the CD4 <350 cells/mm category for subjects with HAART. Overall, DTH response and chance for intact CMI were significantly better in subjects who had CD4 350 cells/mm 3 compared with subjects with CD4 <350 cells/mm. In the univariate linear regression analysis, summed DTH response was significantly and positively associated with a viral load <50 copies/mL, the absolute CD4 cell count, and HAART. In the multivariable analysis, only the absolute CD4 cell count remained significantly and positively associated with the summed DTH response, although there was a trend for the association between summed DTH response and viral load <50 copies/mL (p .149). The antigens that elicited DTH response from largest to smallest were as follows: diphtheria, tetanus, old tuberculin, Candida, Proteus mirabilis, Streptococcus group C, and trichophyton. Our results show that the immune recovery measured by summed DTH response is independent of the HAART regimen. These findings are in accordance with recent studies showing that immune reconstitution achieved after therapy with a PIsparing or PI-containing regimen was similar (13) and independent of virologic efficacy (13,14). Summed DTH response in our study was positively associated with increasing CD4 cell count independent of the HAART regimen or any antiretroviral treatment. A positive correlation between CD4 cell count and JAIDS Journal of Acquired Immune Deficiency Syndromes 32:570–575

Factors Associated with the Acceptance of Immediate Antiretroviral Therapy after HIV Diagnosis in Thai Cohort

BACKGROUND: Since 2014, Thailand has recommend initiation of antiretroviral therapy (ART) immediately after HIV diagnosis, regardless of CD4 count. HIV treatment can prevent illnesses and deaths, avert new infections, and save costs. Achieving UNAIDS 90-90-90 targets by 2020 will enable Thailand to end the AIDS epidemic by 2030. Therefore, patients immediate consent to treatment to immediate ART treatment in people recently diagnosed with HIV are key to successful ART initiation and long-term adherence. We studied factors associated with acceptance of ART initiation among Thai people promptly after their HIV diagnoses. OBJECTIVES: To examine the prevalence and associated factors of consent to immediate initiation of antiretroviral therapy after HIV diagnosis among HIV-positive Thai patients. DESIGN: A cross-sectional descriptive study. SETTING: Anonymous Clinic, Thai Red Cross AIDS Research Centre. MATERIAL AND METHODS: This research is combination of quantitative and qualitative cross-sectional data collected for the purpose of identifying acceptance levels and associated factors with the initiation of ART treatment among people infected. A total of 216 participants were included in the study. Self-administered questionnaire and in-depth interviews were used to collect data from clients 18 years. Binary logistic regression was performed to assess factors related to immediate ART acceptance. RESULTS: Enrollment of participants was 216 and 95.40% indicating they were prepared to start ART immediately and had demonstrated acceptance of their condition and 4.60% chose to defer. 61% were men who have sex with men, 31% were heterosexual, 2% were transgender women and 6% were bisexual men. Median (IQR) age was 29 (24-36) years; median (IQR) CD4 count was 274 (168-396) cells per cubic millimeter. 72% had unprotected sex over the past 6 months, and 9% had HIV-associated symptoms/AIDS-defining illness. Median (IQR) HIV knowledge score was 12 out of 15 (11-13.5), 74% were aware of possible adverse health outcomes and 85% knew about resistance development as a result of poor ART adherence. Multivariable analysis showed that education equal or higher than bachelor’s degree increased acceptance of immediate ART initiation (aOR 0.71, 95%CI 0.008-0.645, P = 0.01). Having STI (aOR 7.822, 95%CI 1.374-44.534, P = 0.02) and obligation (aOR 0.157, 95%CI 0.032-0.770, P = 0.02) were significantly associated with ART acceptance. CONCLUSION: Acceptance of immediate ART after HIV diagnosis was very high among newly diagnosed HIV-positive clients at the Thai Red Cross Anonymous Clinic. Education, experience of STI and obligation consequences influenced ART acceptance.

‘Let Food Be Your Medicine’: a model for HIV nutrition services

Introduction: The positive impact of optimal nutrition on human immunodeficiency virus (HIV) outcomes is well established however there are few examples of HIV being used as a complimentary treatment in outpatient care. The aim of this study is to evaluate the effectiveness of an HIV nutrition project in educating healthcare providers, stimulating the development of provincial nutrition services and building nutritional capacity of people living with HIV (PLHIV). Material and methods: Healthcare providers (HCP) attending a nutrition study trip and demonstration camp were evaluated for their satisfaction and knowledge of HIV nutrition. These interventions were then replicated on a provincial level with the development of hospital nutrition services and camps that in turn were evaluated for attendance, satisfaction and attendee HIV nutrition knowledge. Results: Training of 13 HCP resulted in the instigation of six provincial nutrition camps, one HCP conference, and the establishment of nutrition services and classes attended by over 3111 PLHIV and family members. Satisfaction scores reported by participants in the camps varied from 89% to 98% with HIV nutrition knowledge improving in all instances. Conclusions: This project study demonstrates that HCP and PLHIV are very receptive to the inclusion of nutrition education as part of outpatient HIV care, and that educational interventions can effectively snowball to reach a large number of PLHIV and their families, and improve HIV nutrition knowledge. HIV AIDS Rev 2017; 16, 2: 124-129 DOI: https://doi.org/10.5114/hivar.2017.68020