Robert Fieldhouse reports from the 12th Annual British HIV
Association Conference, Brighton
HAART has changed HIV skin problems
Researchers
are reporting a change in the skin complaints found in people living with
HIV since the advent of highly active antiretroviral therapy (HAART).
Research carried out in an urban, largely African-American group of people
living with HIV, found folliculitis was now the most common skin disease identified,
found in 18 per cent of patients.
The second was warts, in 11.5 per cent, followed by seborrheic
dermatitis (scaly skin) in 10.6 per cent. Dry skin affected 9.7 per cent and
fungal infections 7.1 per cent.
Researchers from Johns Hopkins University in the US examined the initial visits
of 897 HIV positive patients to a dermatology clinic from 1996 to 2002, to
investigate the prevalence and spectrum of HIV-related skin problems.
Just over two-thirds were African-American and around half of these had acquired
HIV through sex, while around 40 per cent had acquired the virus through unsafe
injecting.
Around two thirds had begun HAART before their initial visit to the dermatology
clinic. Folliculitis was diagnosed in 23.8 per cent of patients with low CD4
counts (below 200) compared with 12.9 per cent of those with CD4 counts of
200 and above.
Prurigo Nodularis (seen as red, itchy lumps), was also more common among those
with low CD4 counts, while patients with viral loads greater than 55,000 were
more likely to have idiopathic pruritus and thrush.
Among people on HAART, 6.2 per cent had photosensitivity (sensitivity to sunlight),
compared with 2.9 per cent not on therapy.
Molluscum contagiosum was more common among patients on HAART (5.8 per cent
vs 2.6 per cent), which may have been due to immune recovery syndrome, the
researchers suggest.
“As the treatments for HIV continue to advance, it’s likely cutaneous
manifestations will also continue to evolve and further studies will be required
to adequately assess their changing nature and prevalence,” the investigators
concluded.
Journal American Academy of Dermatology 2006; 54: 581-588
Resistance tests help get good response
to first HIV therapy
People with HIV drug resistance respond as well to starting their first-line
therapy as those without it if resistance testing is used to help select the
drugs, according to a new study.
The findings have prompted the German researchers to call for resistance testing
for all people starting therapy. The team from Düsseldorf studied 269
patients, 30 of whom (11.2 per cent) showed primary HIV drug resistance.
Resistance test results were used to help select their initial HAART (highly
active antiretroviral therapy) combo. They found there was little difference
in the way those with resistant virus responded to their first therapy compared
with those without drug resistance.
After 48 weeks, 83.3 per cent with drug-resistant HIV attained a viral load
below 50 copies compared with 85 per cent of those without resistant strains.
Current guidelines from the British HIV Association recommend drug resistance
testing at the point of HIV diagnosis, before the initiation of first-line
therapy and again at each treatment switch.
But anecdotal reports suggest some clinics are still not adhering to this
guidance. One treatment activist told PN: “Whether or not you get a
resistance test before starting therapy depends on which doctor you see.”
Journal of Acquired Immune Deficiency Syndrome 2006; 41: 573-581
Cell discovery triggers hope for new meds
Scientists have discovered a new cell component that could prevent HIV hijacking
cells.
Emerin is part of a cell’s inner nuclear envelope and is necessary for
HIV-1 to invade human macrophages. This discovery may pave the way for using
small molecule inhibitors of emerin to block HIV infection.
Scientists have long suspected that HIV follows a ‘roadmap’ to
ensure it stays on course towards the cellular chromosomes in the nucleus
of our cells, where it inserts itself.
The researchers said: “Identification of the role of emerin identifies
some of the road signs that make up that roadmap.”
If scientists can identify or develop drugs that ‘silence’ emerin
and prevent interaction of the virus with those ‘road signs’ it
may be possible to disorientate the virus so it can’t establish an infection
in the cell.
Nature, 2006
Quarter of a million hospitalised due to
drug side effects
At least a quarter of a million people in Britain are admitted to hospital
each year because of harmful drug reactions, according to a British Medical
Association (BMA) survey.
Commenting on the findings of the survey, the BMA said: “Adverse drug
reactions (ADRs) accounted for four per cent of hospital bed capacity and
resulted in a projected annual cost to the NHS of £466 million.”
Just over two per cent of patients admitted to hospital with an ADR died.
Estimates suggest only about 10 per cent of ADRs are reported.
Although drugs are tested for potency and safety before approval, sometimes
harmful effects occur in patients only after the drug has been licensed and
prescribed to much larger populations.
Mixing medications and using them with alternative and herbal medicines such
as St John’s wort (used widely to relieve mild depression) can also
produce unwanted results. The report urges doctors, nurses, pharmacists and
patients to report adverse drug reactions to protect health and save lives.
The BMA has also issued advice on reporting ADRs.
Doctors may be confused about the reporting system or may think the side effect
is well known or too trivial to report. It can also be difficult to link an
adverse event to a particular drug.
This is why it’s important to tell your doctor about side effects. Reporting
Adverse Drug Reactions;
A Guide For Healthcare Professionals
Low growth hormone levels common in men with HIV
HIV positive men with body fat changes often have reduced growth hormone levels,
according to
US researchers.
Growth hormone deficiency may be seen in up to a third of HIV positive people
with body fat changes. Body fat changes typically include reduced fat on the
arms and legs and increased fat in the chin and back of the neck.
The team investigated growth hormone response to growth hormone-releasing
hormone plus arginine (an amino acid) stimulation in 139 HIV positive men
and 25 HIV positive women with body fat changes.
They compared responses in 25 HIV negative men and 26 HIV positive women and
found the women showed significantly higher growth hormone responses than
the HIV positive men. Growth hormone deficiency is associated with increased
heart disease risk. The risk could be reduced with a low dose of growth hormone.
Clinical trials investigating this are underway.
AIDS 2006; 20: 855-862
Sex and tattoos put prisoners at risk of
HIV
Research
into men who became HIV positive while in prison in Georgia in the US found
that sex between
men and unsafe tattooing increased the risk of them acquiring HIV more than
ten-fold.
In America, HIV is almost five times more prevalent among prison inmates (2
per cent) compared with the general population (0.43 per cent).
Researchers evaluated 88 men who were HIV negative upon entry into one of
Georgia’s prisons and became infected during imprisonment, sometime
between 1988 and 2005.
Many of the men who had consensual sex reported using condoms or developing
their own improvised methods of protection, such as cutting up rubber gloves
or plastic wraps.
When asked their opinions about how to reduce HIV transmission in prison,
inmates suggested condoms should be made available, along with HIV education,
and safe tattooing.
Condoms are considered illegal in most US prisons, but the authors note that
prisons in two states and jails in five cities currently make them available.
The Georgia Department of Corrections is considering modifying its existing
HIV prevention education as well as housing HIV positive inmates separately.
However, investigators at the Centers for Disease Control fear these strategies
may lead to the disclosure
of inmates’ HIV status and lead to HIV transmission by individuals unaware
they are HIV positive.
Morbidity and Mortality Weekly Report 2006; 55: 421-426
Partial therapy breaks may be safe for children
Simplifying HIV therapy with a partial treatment interruption may be considered
in HIV positive kids on protease inhibitors (PIs) who struggle to take or
tolerate medication, according to new research.
Partial treatment interruptions may also be suitable for those who experience
treatment failure.
During a partial treatment interruption, the youngsters would discontinue
one drug class but continue others.
New York doctors reviewed 26 kids born with HIV who discontinued the PI in
their regimens.
No child experienced clinical disease progression during the 24 to 96 weeks
they were followed and there were no significant changes in viral loads after
the PI was stopped.
CD4 percentage declined over the first 24 and 48 weeks, but the implications
of the decline is unclear as all children remained clinically stable.
A partial treatment interruption may allow doctors to simplify regimens until
new drugs become available, but larger studies are needed to determine who
would benefit, as partial treatment interruption may not be appropriate for
all HIV positive kids.
JAIDS 2006; 41: 298-303
Early Aids-defining illness linked to brain
damage in kids
An Aids-defining illness in children who acquired HIV from their mums is associated
with impaired cognitive development, research suggests.
US researchers followed 117 kids who became HIV positive at birth and 422
children exposed to HIV but who remained HIV negative. Neuro-cognitive development
was assessed at three and seven years.
Children who had had an Aids-defining illness had lower cognitive development
scores than those with HIV but no Aids-defining illness, or those exposed
to but not infected with HIV. The latter two groups had similar levels of
neuro-cognitive development. It’s unclear why a previous Aids-defining
illness should impact upon cognitive ability, but the central nervous system
is a compartment that is very vulnerable to HIV.
Researchers suggested “children who develop Aids very early in life...
may have been infected with the virus during earlier periods of their mother’s
pregnancy, rather than later, during birthing.”
“Being infected during pregnancy may mean either that the baby was infected
for a longer period of time, with longer periods of HIV replication. Or that
the virus and its pathological processes were introduced at a time when critical
brain development was occurring, and resulted in a long-term impact on functioning,”
they concluded.
Pediatrics 2006: 117: 851-861
HIV positive kids often underdosed
HIV
positive children in the UK and Ireland taking antiretrovirals in the last
nine years have often received suboptimal doses of meds. Unlike adults, doses
for children are usually calculated according to their weight and height.
Researchers from the Collaborative HIV Paediatric Study (CHIPS) analysed the
doses prescribed to 615 HIV positive children aged between two and 12 and
compared them against current European guidelines. They found a wide range
of doses were prescribed for individual antiretrovirals.
The researchers blamed, in part, poor pharmacokinetic data at the time of
drug licensing as well as failure by some doctors to adjust the dosing to
reflect the child’s ongoing growth. They said: “The findings underline
the importance of research on suitable formulations, dosages, and efficacy
of drugs for children with chronic diseases.”
BMJ 2006; 332: 1183-1187
AZT has no impact on children’s growth
Exposure to AZT in the womb or after birth appears to have no impact on children’s
growth rates in the first 18 months of life. But children exposed in the womb
were more likely to be of lower birth weight.
The findings come from a trial involving 1,408 children in Thailand testing
different lengths of AZT treatment.
Babies exposed to AZT in the womb for more than 7.5 weeks were more likely
to weigh less, but AZT exposure had no impact on change of weight for age
or height for age, during the first 18 months of life.
The researchers concluded that while a longer in utero exposure to AZT might
have a negative impact on birth weight, the magnitude of this effect is small
and fades over time.
PIDJ 2006; 25: 325-332
PI therapy linked to premature delivery
Protease inhibitors (PIs) appear to be the only class of HIV drug linked to
babies being born prematurely to HIV positive women.
Researchers studied the records of more than 1,300 women who had given birth
at the University of Miami Jackson Memorial Medical Center between 1990 and
2002 to see if there was a link between premature delivery, low birth-weight
or stillbirth and antiretroviral therapy.
Just over a third (492) had received one drug antiretroviral therapy, 373
(28 per cent) had received combination therapy without a protease inhibitor
(PI) and 134 (10 per cent) received combination therapy with a PI during pregnancy
and 338 women (26 per cent) who did not receive therapy during pregnancy.
Researchers concluded that only PI therapy increased a woman’s risk
of premature delivery. They found no increased risks of low birthweight or
stillbirth in women receiving antiretrovirals.
Journal of Infectious Diseases, 4/4
Vitamin A for HIV positive mums and babies
can ‘help and harm’
Giving a single large dose of vitamin A to HIV positive women and their
newborns after delivery fails to reduce mother-to-child HIV transmission.
It does however improve survival of children who are HIV positive at six weeks,
latest research shows.
Unfortunately, in HIV negative breast-fed infants, a large dose of vitamin
A to the mother or baby may actually increase the likelihood of the babies
dying.
This had led to concern about instituting universal vitamin A supplementation
in areas with high HIV rates. The World Health Organisation recommends a single
large dose of vitamin A for postpartum women living in areas of the world
where vitamin A deficiency is common.
Doctors in Zimbabwe assessed the impact of giving the mother, infant, both,
or neither a single large dose of vitamin A in the days following the birth.
In total, 4,495 infants born to HIV positive women were included. Nearly all
of the mums breastfed their babies.
Vitamin A supplementation of the mother or baby had no effect on postnatal
mother-to-child HIV transmission or of the babies’ chance of dying for
up to 24 months. But for babies who were HIV negative at the start of the
study and who tested positive at six weeks, vitamin A supplements reduced
their chance of dying by 28 per cent, but maternal supplementation had no
effect.
Infants who were HIV negative at birth and continued to show no evidence of
HIV infection at six weeks seemed adversely affected by the vitamin A. Compared
with children who did not receive the supplement, they were almost twice as
likely to die.
Journal Infect Dis 2006; 193, 860-871
Nelfinavir safe long-term in children with
HIV
Antiretroviral
treatment containing the protease inhibitor nelfinavir (Viracept) is safe
for long-term use in infants and children with HIV, according to latest research.
Researchers evaluated the long-term virologic, immunologic and clinical safety
and effectiveness of antiretroviral treatment with nelfinavir, d4T (stavudine)
and 3TC (lamivudine) in 39 HIV positive kids.
The children were treated for an average of 185 weeks as part of the Pediatric
Amsterdam Cohort on HIV (PEACH).
CD4 counts rose in the first 48 weeks of therapy, regardless of whether treatment
failure occurred. None developed an Aids-defining illness or died while receiving
treatment, but 11 children (28 per cent) developed body fat changes after
an average of 49 months. Twenty-six discontinued treatment because of virologic
failure, two through major toxicity, one poor palatability and refusal and
four received a simplified therapy.
Seven children who discontinued had never achieved an undetectable HIV viral
load. It took an average of almost eight weeks to reach undetectable. Twenty-two
children subsequently experienced treatment failure but 16 of these continued
to take their study medication for an average of 3.3 years after failure.
Because of the high rate of treatment failure and body fat changes that occurred
at a young age, research still needs to focus on adherence, the effects of
long-term exposure to antiretroviral therapy and side effects. Simplified
options and smaller pills for kids are urgently needed Pediatrics 2006; 117:
e528-e536
