Special Coverage of the 2000 IDSA Conference
IDSA research shows change in HIV progression
Opportunistic infections highlighted
The recent Infectious Diseases Society of America (IDSA) conference, held Sept. 7-10, 2000, in New Orleans, presented a body of research on HIV that demonstrates how investigators anticipate major changes in the course of HIV treatment. Much of the research focused on HIV patients’ comorbidities and opportunistic infections in the age of highly active antiretroviral therapy (HAART).
Here is a brief summary of some of the abstracts presented at the conference:
• Pneumococcal infections: Investigators from the Centers for Disease Control and Prevention in Atlanta, Johns Hopkins University in Baltimore, and the University of Pittsburgh presented an abstract on a study of recurrent invasive pneumococcal infections in HIV-infected patients.
Their research found that most patients who have recurrent pneumococcal disease have been reinfected with a new strain. All of the strains found to be involved in relapsing disease are included in the 23-valent pneumococcal polysaccharide and the 7-valent pneumococcal conjugate vaccine.1
• Latent tuberculosis infection: Researchers from Emory University and Emory University School of Medicine in Atlanta investigated the optimal time to perform purified protein derivative (PPD) testing to identify latent tuberculosis infection after the initiation of HAART.
Investigators found that a patient’s current CD4 cell count is the best predictor of the patient’s ability to respond to delayed-type hypersensitivity skin testing, and PPD testing should be considered once a patient’s CD4 cell count exceeds 100 cells/mm3 after treatment with HAART.2
• Comorbidity among HIV patients: Investigators at Parkland Health and Hospital System in Dallas and Clinical Partners of San Francisco analyzed trends in HIV clinical status and number and type of comorbidities in a cohort of 335 HIV-positive patients between 1996 and 1999.
Investigators assessed these 17 key comorbidities: treatment with antidepressants/antipsychotics, cardiac arrhythmia, cervical dysplasia, diabetes, heart failure, hepatitis, herpes, hyperlipidemia, hypertension, ischemic heart disease, kidney stones, lipodystrophy, necrosis, non-PCP pneumonia, pregnancy, chronic respiratory disease, and tuberculosis.
The study concluded that as HAART use increased, patients’ HIV clinical status improved, but the average number of comorbidities per patient increased dramatically.3
• Increasing incidence of steatohepatitis and lactic acidosis: A researcher at St. Vincent’s Hospital and Medical Center in New York City investigated obesity-related, nucleoside analog-associated steatohepatitis and lactic acidosis in HIV-infected patients.
The study, which focused on six cases of steatohepatitis and lactic acidosis among obese, HIV-infected patients, suggests that obesity might be a predisposing factor for mitochondrial dysfunction in HIV-infected patients treated with nucleoside analog reverse transcriptase inhibitors (NRTIs). Therefore, clinicians might wish to consider NRTI therapy to be contraindicated in some obese HIV-infected patients.4
• Cardiovascular risk in HIV patients: Researchers from the University of Cincinnati College of Medicine investigated whether HIV-infected people were at risk for the development of ischemic cardiovascular disease (CVD) due to treatment-associated metabolic complications, underlying cardiovascular risk factors, or other mechanisms.
They conducted a retrospective, case-control study of 15 HIV-infected patients with proven CVD who were seen between April 1, 1999, and April 25, 2000. The control group included HIV-infected patients who had no known CVD but who were similar in age and gender the control group. The investigators found that when compared to the control group, the HIV patients with CVD had more pre-existing risk factors and a lower nadir CD4+ lymphocyte count. This study found no clear association between the use of protease inhibitors and the occurrence of CVD.5
• Loss of bone mass: Investigators at the University of North Texas Health Sciences Center in Fort Worth assessed 29 HIV-infected people for their degree of bone loss in a pilot study.
Using dual energy X-ray absorptiometry, investigators found abnormal scans in 16 individuals who were less than 40 years of age. Men at greatest risk of fracture in the femur had CD4 cell counts of less than 200 cells/mm3. While not identifying any causes of the decreased bone density, the study suggested that additional investigation should clarify the incidence of bone loss among HIV patients and also determine whether progressive loss occurs over time.
Incidence of Kaposi’s sarcoma has declined
• Four AIDS-related malignancies: Baylor College of Medicine in Houston researchers studied the impact of antiretroviral therapy on the incidence of four AIDS-related malignancies, including Kaposi’s sarcoma, systemic non-Hodgkin’s lymphoma, Hodgkin’s disease, and cervical carcinoma.
Investigators found that the incidence of Kaposi’s sarcoma has significantly declined since the advent of HAART, but there was no similar finding in the incidences of the three other malignancies.7
In the period 1992-1995, the incidence of Kaposi’s sarcoma was 12.4 per 1,000 person-years, compared with 9.4 per 1,000 person-years in the 1996-1999 time period. For non-Hodgkin’s lymphoma, the 1992-1995 incidence was 8.6 per 1,000 person-years, and the incidence in 1996-1999 was 6.5 per 1,000 person-years. In 1992-1995, the incidence of Hodgkin’s disease was 0.7 per 1,000 person-years, compared with 1.3 per 1,000 person-years in 1996-1999. And for cervical carcinoma, the 1992-1995 incidence was 0.2 per 1,000 person-years , compared with 0.9 per 1,000 person-years in the 1996-1999 time frame.
• Lactic acidosis in hospitalized HIV patients: A second study examining lactic acidosis, this one from the University of Alabama at Birmingham School of Medicine, assessed the clinical features and incidence of lactic acidosis among hospitalized HIV-infected patients who had been on NRTI therapy.
Investigators reviewed cases from January 1995 to February 2000 and found 12 subjects who presented with either abdominal pain or nausea or emesis. The study concludes that there are an increasing number of lactic acidosis syndrome cases in NRTI-treated HIV-infected subjects, which could reflect cumulative long-term toxicity.8
References
1. McEllistrem MC, Pass MA, Elliott JA, et al. Molecular epidemiology of recurrent invasive pneumococcal infections in HIV-infected patients in the Baltimore metropolitan area. Abstract #12 presented at the Infectious Diseases Society of America conference. New Orleans; Sept. 7-10, 2000.
2. Fisk TL, Hon HM, Lennox JL, et al. Testing strategy for latent tuberculosis infection (LTBI) after initiation of highly active antiretroviral therapy (HAART). Abstract #13 presented at the Infectious Diseases Society of America conference. New Orleans; Sept. 7-10, 2000.
3. Rawlings MK, De Guzman C, Slaker R, et al. Comorbidity and clinical indicators in a cohort of 335 HIV+ patients 1996-1999. Abstract #324 presented at the Infectious Diseases Society of America conference. New Orleans; Sept. 7-10, 2000.
4. Revuelta MP. Increasing incidence of nucleoside analog-associated steatohepatitis and lactic acidosis in obese HIV-infected persons. Abstract #352 presented at the Infectious Diseases Society of America conference. New Orleans; Sept. 7-10, 2000.
5. David MH, Fichtenbaum CJ. A case-control study of cardiovascular risk in persons with HIV infection. Abstract #355 presented at the Infectious Diseases Society of America conference. New Orleans; Sept. 7-10, 2000.
6. Atkinson BA, Blais FX, Rubin BR, et al. A pilot study to define the degree of loss of bone mass in HIV infected individuals. Abstract #356 presented at the Infectious Diseases Society of America conference. New Orleans; Sept. 7-10, 2000.
7. Vilchez R, Kozinetz C, Kroll MH, Butel JS. The influence of antiretroviral therapy on the incidence of four AIDS-related malignancies in a large urban center. Abstract #376 presented at the Infectious Diseases Society of America conference. New Orleans; Sept. 7-10, 2000.
8. Coghlan ME, Sommadossi JP, Many WJ, et al. Lactic acidosis in hospitalized HIV-infected patients treated with nucleoside reverse transcriptase inhibitors. Abstract #376 presented at the Infectious Diseases Society of America conference. New Orleans; Sept. 7-10, 2000.
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