The British HIV Association held its annual meeting at Churchill College, Cambridge, on March 26-28. Besides overview presentations on current issues (summarised elsewhere on this site: see Anti-HIV Therapy), the meeting is also an opportunity for clinicians to present clinically relevant data from small cohorts and to alert colleagues to emerging trends and adverse events.
Asymptomatic urethritis and seminal HIV
Dr. Andrew Winter from Birmingham's Whittall Street Clinic reported on asymptomatic urethritis in HIV-positive men. Seven out of 87 men had asymptomatic urethritis (1 asymptomatic chlamydia and 6 cases of non-specific urethritis). The mean age of men with asymptomatic urethritis was lower than the mean for the group as a whole, at 29 years. Four of the seven men had detectable HIV RNA in their semen measured by PCR (mean RNA = 11,000 copies) despite receiving anti-retroviral treatment; all had recently changed or started treatment.
Hospital admissions in patients with undetectable viral load
Dr Andrew Shaw reported on 67 recent in-patient admissions of patients with undetectable viral load at the Chelsea and Westminster Hospital. 10% of all HIV in-patient admissions between January 1997 and October 1998 occurred in patients with viral load below 400 copies per ml. The most common reason for admission was complications due to HAART: 12 out of 16 HAART complications were renal colic or kidney stones related to indinavir treatment, whilst three admissions due to severe nausea were also reported. Development of new opportunistic infections was rare. One new case of MAI was reported, together with two relapses in individuals with very low CD4 counts and very short periods on treatment. Three cases of PML were also reported; the effects of HAART on the progression PML have been uneven. One case of PML was diagnosed in an individual with 111 weeks of prior HAART.
Two out of three KS related admissions occurred in individuals with pre-existing KS, but one new case requiring hospital admission was reported. Two individuals were admitted after adverse reactions to Ecstasy; both had extensive prior experience of Ecstasy and interaction with protease inhibitors was suspected in both cases.
PEP poorly tolerated by health care workers
Two groups reported on the effects of post-exposure prophylaxis amongst health care workers at St Bartholemew's Hospital, London, and Edinburgh Royal Infirmary. St Bartholemew's reported that the standard PEP regimen of AZT/3TC/indinavir was poorly tolerated; six out of nine who received indinavir did not complete a 28 day course and dropped this component of the regimen, and four out of nine required between 2 and 28 days off work due to side effects. There were no discontinuations amongst five patients who received saquinavir. Ten of the donors were taking or had taken two or more drugs which formed part of the recommended PEP regimen (Parkin).
The Edinburgh group reported that PEP was tailored according to the treatment experience of the index case, with less consequent use of indinavir; only one individual discontinued treatment before the end of the 28 day period. The median time in this group from injury to initiation of PEP was 55 minutes (range 23-150 minutes), well within the recommended time frame for initiating treatment, indicating that a rapid response service is possible. Six individuals did not complete the course because the index case subsequently tested HIV-negative (Paterson).
Lymphoma treatment
A team from the Chelsea and Westminster Hospital reported on responses to lymphoma treatment in HIV-positive patients. Lymphoma is being seen more frequently in comparison with other opportunistic infections, perhaps because HAART-mediated immune restoration has less effect on the development of lymphomas than on other opportunistic illnesses.
Dr Mark Nelson reported on the use of BEMOP/CA in 30 patients. BEMOP/CA is a regimen which alternates weekly infusions of bleomycin, etoposide, methotrexate and vincristine with weekly infusions of cyclophosphamide and doxorubicin over 12 weeks. Patients were selected for this regimen if they had no more than one adverse prognostic factor (of prior AIDS diagnosis, CD4 count , 100, Karnofsky score less than 70 or primary cerebral involvement). Two year lymphoma-specific survival was 60%, but overall survival was 45%. Two thirds of patients did not receive HAART, and fifteen out of thirty were receiving no anti-retroviral therapy at all at diagnosis. In a separate group of patients receiving protease inhibitor-containing regimens at the time they commenced HAART (n=5), a trend towards large CD4 decreases was seen, although this was not statistically significant. It was suggested that this loss of CD4 cells during chemotherapy is due to a fall in absolute lymphocytes rather than a CD4-specific decline; CD4 cells returned to baseline after chemotherapy stopped (Nelson; Moore).
Treatment advances most common reason for testing
A survey of younger gay men under 25 who attended the Axis clinic at the Mortimer Market Centre, London, showed that a perception of HIV treatments as being more effective was cited by 56% as a major reason for testing (McOwan).
Micronised fenofibrate as treatment for hyperlipidaemia
Brighton researchers reported on the use of micronised fenofibrate (Lipantal Micro) 200mg qd in 10 patients and 200 mg bid in 2 patients with mean cholesterol levels of 11.3mmol/l and mean triglyceride levels of 14.5mmmol after a mean of 13.8 months of protease inhibitor treatment. Cholesterol levels fell to a mean of 8.3mmol/l after treatment with fenofibrate, and triglyceride levels fell to a mean of 7.6mmol/l. Reduction in body fat maldistribution was noted in only one patient after treatment (Curry).
Osteoporosis in African women on HAART
A team from the Royal Free Hospital reported on two sudden onset cases of osteoporosis in younger African women on HAART. Osteoporosis is rare in younger, pre-menopausal women, especially in African women. Two cases in African women were seen at the Royal Free Hospital in 1998.
In both cases sudden onset lumbar pain alerted clinicians to the condition, after emergency admission for unconnected opportunistic infections. In both cases menstrual periods had been interrupted prior to the onset of lumbar pain. Bone mineral densitometry confirmed osteoporosis in both cases after bone scans showed collapse of a number of bones.
One patient was receiving treatment with d4T, 3TC and nevirapine, whilst the other was receiving a salvage regimen of ddI, hydroxyurea, efavirenz, nelfinavir and saquinavir. None of the other medications being used by the women are known to be associated with changes in bone density or prolactin levels (Stephens).
Paradoxical resolution of peripheral neuropathy after commencing d4T
Doctors from Dublin reported the case of a 29 year old man with demyelinating peripheral neuropathy who commenced d4T/3TC/nelfinavir (a regimen chosen for ease of adherence) after presenting with a viral load of 430,000 and substantially impaired use of his hands and feet necessitating regular pain relief.
After three months his neuropathy had resolved and and an electromyelogram showed almost complete reversal of the abnormalities. His viral load was suppressed below 50 copies. D4T is usually contraindicated in cases of pre-existing peripheral neuropathy because of its capacity to aggravate the condition, but the authors suggested that in this case immune reconstitution (a CD4 increase from 73 to 217 over three months) and viral suppression had allowed an HIV-mediated neuropathy to be repaired (Clarke).
Failure to control visceral leishmaniasis despite good response to HAART
Visceral leishmaniasis is occasionally reported in patients with HIV of African, Asian or Southern European origin. Dr David Asboe of the Chelsea and Westminster Hospita reported on three cases in which visceral leishmaniasis recurred despite viral suppression below 500 copies with HAART. In two cases, three histologically proven recurrences have occurred, whilst in the third a single recurrence has been reported. Length of time between response to initial VLM treatment and recurrence varied between 5 and 23 weeks, and in two cases further relapses occurred approximately 23-25 and again 30-33 weeks later (Asboe).
Asboe D et al. Failure to control visceral leishmaniasis despite effective introduction of HAART. Fifth Annual Meeting of the British HIV Association, abstract P45, 1999.
Clarke S et al. Resolution of peripheral neuropathy with antiretroviral therapy. Fifth Annual Meeting of the British HIV Association, abstract P36, 1999.
Curry KM et al. Treatment of protease-associated hyperlipidemia with micronised fenofibrate. Fifth Annual Meeting of the British HIV Association, abstract P17, 1999.
Moore A. Changes in CD4 count and viral load during chemotherapy for AIDS-related lymphomas. Fifth Annual Meeting of the British HIV Association, abstract P47, 1999.
Moore EJ et al. Lipid perturbation: a protease inhibitor-specific problem? Fifth Annual Meeting of the British HIV Association, abstract 27, 1999.
Moyle G et al. Salvage therapy with abacavir and efavirenz or nevirapine in HIV-1 infected persons with CD4 cell counts <100/mm3 and prior protease inhibitor therapy. Fifth Annual Meeting of the British HIV Association, abstract 27, 1999.
Nelson M et al. Outcome with weekly alternating combination chemotherapy for good prognosis AIDS-related lymphoma. Fifth Annual Meeting of the British HIV Association, abstract P48, 1999.
Parkin J et al. Tolerance of post-exposure prophylaxis in health care workers. Fifth Annual Meeting of the British HIV Association, abstract O21, 1999.
Shaw AJ et al. Why are individuals with an undetectable viral load still admitted to hospital? Fifth Annual Meeting of the British HIV Association, abstract O5, 1999.
Stephens E et al. Symptomatic osteoporosis in two young African women with advanced HIV. Fifth Annual Meeting of the British HIV Association, abstract P34, 1999.
Winter AJ et al. Asymptomatic urethritis and detection of HIV-1 RNA in seminal plasma. Fifth Annual Meeting of the British HIV Association, abstract O1, 1999.