Spotlight: Conference Update 2002
Selected news from the 42nd Interscience Conference on Antimicrobial Chemotherapy (ICAAC) held September 27-30, 2002 in San Diego; the 26th annual meeting of the National Commission on Correctional Health Care (NCCHC) held October 19-23, 2002 in Nashville; and the 40th conference of the Infectious Diseases Society of America (IDSA) held October 24-27, 2002 in Chicago.1
NCCHC: The recently released report to Congress entitled "Health Status of Soon to be Released Inmates" highlights the unique opportunity that correctional health care professionals have to diagnose and treat sexually transmitted diseases. Data presented by Kennedy et. al. from seven juvenile detention centers revealed an average infection prevalence of 7.1% for chlamydia (CT) and 2.6% for gonorrhea (GC). The same group reported that for incarcerated adult women <25 years-old from three U.S. cities, the prevalence of CT was 15-22% and that of GC was 8-9%. Infections were detected utilizing the urine ligase chain assay. Both CT and GC can be eradicated with a single dose of an antibiotic.
NCCHC: Varghese, Lincoln et. al. from the Hamden County Correctional Center in Massachusetts presented an economic analysis of an HIV testing and counseling program that demonstrated that routine testing of inmates is effective in identifying new cases of HIV, and has the potential to prevent future infections and decrease health care expenditures.
NCCHC: Newman et. al. presented an epidemiological analysis of CT and GC in women incarcerated by the Federal Bureau of Prisons (FBOP). This study demonstrated that in the FBOP, limiting screening to women <31 years of age diagnosed more than half of the cases at a fraction of the cost of screening all women.
IDSA abstract #29: This CDC study of the HIV counseling and testing database evaluated the rate of return of HIV test results. In 2000, of 1,641,488 people tested, 15,037 were HIV-infected. Test results were two times more likely to be returned to people if they were incarcerated at the time of testing. This data reinforces the importance of jail and prison-based testing programs.
IDSA abstract #653: 293 HIV-infected individuals with genital HSV were randomized to receive either twice-daily oral valacyclovir or placebo. At six months, 80% of those receiving valacyclovir were recurrence-free, opposed to 38% of those receiving placebo. Genital ulcer disease is known to increase the risk for transmission of HIV. Thus, the use of prophylactic oral acyclovir or valacyclovir in those with a history of recurrent genital HSV has the potential to both decrease recurrence of HSV and transmission of HIV.
ICAAC: 1494 heterosexual couples discordant for HSV-2 infection at 96 sites worldwide were randomized so that the HSV-infected individual received either daily valacyclovir or placebo. The partners of 3.8% of those receiving placebo vs. 1.9% of those receiving valacyclovir developed infection with HSV. This study suggests that HSV-2 infected partners of those who are HSV-2 negative should be offered prophylaxis.
IDSA abstract #662: This San Francisco study found a high incidence of proctitis in a cohort of men who have sex with men. Most cases were due to syphilis, NG, CT, and/or HSV. As active proctitis is known to increase the risk for acquisition of HIV, it should be promptly diagnosed and treated.
IDSA abstract #655: This study from Seattle found that 33/100 asymptomatic undergraduate men were culture positive for human papillomavirus (HPV).
IDSA: Exciting news was presented concerning a vaccine to pre-vent acquisition of HPV. (See also NEJM 11/21/02). Approximately 450,000 women worldwide develop cervical cancer annually, with a mortality of ~50%. In the developing world, cervical cancer is one of the leading causes of cancer deaths. In the U.S., ~15,000 cases of cervical cancer occur each year resulting in 5,000 deaths. The vaccine discussed is directed at HPV type 16, which is responsible for about half of the cases of cervical cancer. The vaccine was tested on women 16-23 years-old at 16 sites nation-wide. Women were followed on average for 18 months. Of 768 women vaccinated, none developed HPV type 16 infections or precancerous lesions. Of the 765 who received placebo, 41 developed persistent HPV 16 infection and 9 developed precancerous tissue changes. Vaccinated women developed antibody titers against HPV 16 that are ~60 times greater than those seen in naturally occurring infection. An international phase 3 study is under way utilizing a tetravalent vaccine with serotypes 16, 18, 31, 45. Together, these four serotypes are responsible for 80% of cervical cancer.
IDSA abstract #21: The prevalence of flouroquinolone (FQ) resistant GC is known to be high in Asia and Hawaii. This CDC study of NG at four sites in northern and southern California found an overall prevalence of resistance to FQ of 4.9%. Higher resistance rates were seen in Asians, IDU, and those with recent antibiotic use. Therefore, FQ can no longer be considered first-line therapy for NG in CA or for patients who acquired GC there.
NCCHC: Clark, Sylla, and Gaylord presented a one-year report on the L.A. County jail condom distribution program. This initiative, which provides condoms and risk reduction education to self-identified gay, bisexual, and transgendered inmates, has been well accepted by staff and inmates and lead to no disciplinary issues.
IDSA abstract #793: The HCV seroprevalence among incoming inmates to the NYS prison system in 2000-2001 was 23% among women and 13.4% among men. The rate of HIV co-infection was 5.6% in women and 2.3% in men. Even among non-IDUs, the prevalence of HCV was 14% in women and 9% in men. This data suggests that inmates should be counseled and screened for HCV even in the absence of identified high-risk behaviors.
IDSA abstract #517: This study of HCV prevalence among the urban poor in San Francisco demonstrated a prevalence of HCV of 69%. Patients were recruited from hotels, shelters, and free lunch sites. Among those infected with HCV, a history of treatment was rare with <2% of patients entering into treatment each year.
IDSA abstract #527: Among HIV-infected patients vaccinated for HAV, only 60% developed a protective antibody titer. Those with CD4 >200 were two times more likely to respond to vaccination.
ICAAC and IDSA: Both had numerous abstracts looking at use of 3TC, adefovir, and/or tenofovir in the treatment of chronic hepatitis B infection. All three agents have the potential to decrease HBV viral load and liver inflammation. In a minority of patients, loss of e antigen positivity can be achieved. Studies are ongoing utilizing combination therapy targeted at HBV in mono-infected and HIV co-infected patients.
ICAAC: Follow-up data was presented from Gilead 903 demonstrating that at 48 weeks, 80% of those receiving efavirenz (EFV) plus 3TC plus either d4T or tenofovir had HIV VL <50 copies. Previously, ACTG 384 established that in terms of time to virologic failure, AZT/3TC/EFV is superior to AZT/3TC/NFV, d4T/ddI/NFV, or d4T/ddI/EFV in treatment-naïve patients. Considered together, these studies further support the use of an EFV/3TC backbone coupled with abacavir, AZT, ddI, d4T, or tenofovir in the treatment of HAART-naïve patients.
ICAAC H-1076: BMS A1424-034 data was presented comparing AZT/3TC/EFV to AZT/3TC/atazanavir (BMS's new once-a-day protease inhibitor.) As compared to other PI regimens, atazanavir (ATZ) has been shown to lead to minimal lipid changes. ATZ can cause asymptomatic elevations in indirect bilirubin.
Previous studies suggested that virologically, ATZ has efficacy similar to nelfinavir (NFV), while NFV has been shown to be less effective in naïve patients than EFV. Surprisingly, A1424-034 found that both the ATZ and EFV arms had comparable efficacy in achieving HIV VL of <400 and <50. It should be noted however that both arms were significantly less successful than has been seen in prior EFV studies. (HIV VL <400: 70% in the ATZ arm, 64% in the EFV arm; HIV VL <50: 32% in the ATV arm, 37% in the EFV arm). Although a true once daily PI is a welcome addition, further study is needed before ATZ can be considered to be virologically equivalent to EFV.
ICAAC H-165: Through four years of follow-up, HAART-naïve patients receiving Lopinavir-ritonavir (LPV-rtv) demonstrated sustained virologic response (intent to treat analysis: 70% HIV VL <50; on treatment analysis, 97% VL <50). Of those with viral load rebound, no PI resistance mutations have been demonstrated. LPV was well tolerated.
ICAAC H-161: 554 treatment-naïve patients were randomized to 300 mg po qd or 150 mg bid of 3TC coupled with once-daily EFV and twice-daily AZT. At 48 weeks, both arms demonstrated equivalent antiviral efficacy, adverse events, and frequency of the 184 mutation. 3TC has now been approved for once-a-day dosing, and a new 300 mg formulation is available.
ICAAC H-166: Fosamprenavir is a prodrug of amprenavir (APV) that is well tolerated, has no food restrictions, and is dosed as two pills bid as compared to eight bid for APV. The NEAT trial was reported at ICAAC, and demonstrated comparable virologic efficacy for fosAPV/3TC/ABC as compared to NFV/3TC/ABC.
ICAAC: Toro 2 studied HAART-experienced patients in Europe and Australia who are resistant to medications in all three classes and/or have a history of prolonged use of HAART. This study evaluated the addition of T-20 (fusion inhibitor) by bid injection vs. placebo to an optimized background of three to five other agents. The T-20 arm demonstrated a 1.70 decrease in the HIV VL as compared to a .76 drop in the optimized background arm alone.
ICAAC H-1074: This study looked at the result of substituting ABC or AZT for d4T in patients with either lipoatrophy (as deter-mined by self-report or physical examination) or elevated serum lactate (>3.2 without symptoms, >2.2 with symptoms). Patients were studied by dexa scan, CT, self-report, and anthropomorphic measurements. Patients who switched from d4T demonstrated increased fat in arms and legs by dexa scanning; decreased lactate levels; and significant improvements in lipoatrophy (by self report) with increased fat in face, legs, arms, and buttocks.
ICAAC: Previously, the Gilead 903 study demonstrated equivalent virologic efficacy of EFV/3TC/TFV vs. EFV/3TC/d4T. At ICAAC, further analysis of this study was presented which showed that the d4T arm had an increased incidence of elevated serum lactate, hyperlipidemia, (cholesterol, fasting triglycerides, LDL), and neuropathy as compared to the TFV arm.
Joseph Bick is co-chief editor of HEPP Report.
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This article was provided by Brown Medical School. It is a part of the publication HEPP Report.