Opportunistic, Intercurrent Infections and Malignancies
PCP
In a study that also has relevance to antiretroviral therapy, the efficacy of education in improving adherence to PCP prophylaxis was evaluated in patients at an inner city institution by randomization to usual care or to nurse-based directed interviews at the end of each scheduled clinic visit. Although the intervention group was demonstrated to have improved knowledge of PCP, there was no difference in adherence to prophylaxis as determined by use of the Medication Monitoring Systems (MEMS) device. In addition, although 96% of the patients could read their medication label, 22% were unable to interpret it correctly. (Abstract I-178.)
Accumulating data suggest that it may be safe to discontinue PCP prophylaxis in some patients who have had significant responses to HAART. PCP prophylaxis was discontinued in 45 patients whose CD4 count had risen above 200/mm3 after institution of highly active antiretroviral therapy. The mean CD4 count at the time of discontinuation was 335/mm3 (range, 200-963/mm3) and the mean viral load was 3.35 log10/mL (range, undetected to 5 log10/mL). No cases of PCP have occurred after a mean prophylaxis follow-up of 329 days (range, 46-1334 days). (Abstract I-204.) Separately, PCP prophylaxis was discontinued in 26 patients under similar circumstances. No cases of PCP occurred after a mean follow-up of 291 days. (Abstract I-206.) No cases of PCP occurred in 21 patients followed for a mean of 8.5 months whose primary prophylaxis was discontinued. (Abstract I-262.) Finally, no cases occurred after a mean follow-up of 12.5 months in 60 Dutch patients whose primary prophylaxis was discontinued or, after a mean follow-up of 6.6 months, in 13 whose secondary prophylaxis was discontinued. (Abstract I-269.)
Mycobacterial Infections
Immune response disease is sometimes seen in patients in the months after introduction of successful HAART. Six of 10 cases of MAC infection in patients receiving highly active antiretroviral therapy were localized rather than disseminated. Two each had osteomyelitis, mesenteric lymphadenitis, and mediastinal adenopathy with bronchial compression. Four of these patients had received treatment for MAC and had plasma HIV RNA of less than 200 copies/mL. (Abstract I-105.) These manifestations are likely the result of a newly developed inflammatory response to an infection that was present prior to the institution of HAART.
Mycobacterial lymphadenitis, which presents within 12 weeks of initiating effective antiretroviral therapy, is usually due to MAC and is not part of a disseminated infection. (Abstract I-264.)
Coadministration of clarithromycin increases the amprenavir AUC by 18%; 14-hydroxylation of clarithromycin is inhibited. (Abstract A-73.) A decrease in concentrations of the latter may impair the usefulness of this drug in the treatment of Haemophilus influenzae infections.
CMV
CMV viremia (by PCR) became undetectable in 16 of 16 patients following the institution of highly active antiretroviral therapy after a median interval of 13.5 weeks. All but two remained CMV negative by PCR for a median of eight months. (Abstract I-268.)
A retrospective comparison of 14 patients given HAART following a diagnosis of CMV retinitis to a control group of 14 with CMV not given HAART, found that survival in the former group at two years was 75%, while it was only 3% in the latter group (P < 0.00001). Similarly, HAART was associated with a reduction in the proportion of patients whose retinitis relapsed from 100% to 36%, with all relapses in the latter group occurring during the first five months of HAART. The downside of this success is that of inflammatory ocular responses resulting from immune reconstitution. Thus, inflammatory vitritis was frequently seen in HAART recipients, but not in the group not receiving HAART. (Abstract I-270.)
Anterior uveitis may occur during cidofovir therapy of CMV retinitis. The investigators believe it to possibly be the result of intraocular accumulation of the drug. (Abstract H-112.)
Malignancies
HAART is associated with improved survival of patients with non-CNS non-Hodgkin’s lymphoma. Compared to a median survival of six months, a previously reported cohort given HAART had a median survival of approximately two years. (Abstract I-265.)
Administration of either foscarnet or ganciclovir has no effect on circulating HHV-8 (KSHV) DNA load. (Abstract H-113.)
PML
HAART was instituted in 11 patients with progressive multifocal leukoencephalopathy and their outcomes were compared to those of 23 patients previously treated with Ara-C. The median time to survival was approximately two months in each cohort, suggesting no benefit from HAART. (Abstract I-273.)
Hepatitis Viruses
The clinical course of acute HAV infection does not appear to be more severe in HIV-infected patients than in non-HIV infected patients. (Abstract H-114.)
In patients coinfected with HBV whose HBV is responding to 3TC, hepatitis may worsen if the 3TC is discontinued. (Abstract H-119.)
HIV-infected patients are commonly coinfected with HCV, with by far the highest rates of coinfection in injection drug users. Successful HAART does not lead to reduced plasma HCV RNA levels. (Abstract H-111.) In fact, institution of HAART may be associated with a transient increase in HCV levels.
Q Fever
Acute Q fever in 10 HIV-infected patients appeared to be of comparable severity to that encountered in non-HIV infected individuals. (Abstract I-131.)
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