HIV/AIDS Newsroom: January 5, 2000
Association of Initial CD4 Cell Count and Viral Load With Response to Highly Active Antiretroviral Therapy
Journal of the American Medical Association
In a research letter to the Journal of American Medical Association, researchers from Johns Hopkins University School of Medicine report a retrospective comparison of the outcomes of starting highly active antiretroviral therapy (HAART) at different CD4 cell count and viral loads. The authors focused on reduction of HIV RNA to less than 400 copies in at least one instance within six months of beginning therapy (initial response) and response with no following increase in HIV RNA to over 1,000 copies (durable response). Nearly two-thirds of the patients achieved HIV RNA loads of less than 400 copies, while only 42 percent of the initial responders and 27 percent overall had durable responses. Based on their findings, the researchers recommend that the initial timing of HAART take into account both viral load and CD4 cell count, as the data seems to suggest that the therapy may have a better chance of success in suppressing viremia if given before the disease advances to moderate or severe infection.
In Maryland, Montgomery County officials have decided to test dozens of students and faculty members at Montgomery Blair High School for tuberculosis following the diagnosis of a student with the disease. Only the students and faculty who had contact with the student during classes are required to be tested. Health officials said that the student was no longer in the contagious stage of the infection and that there was minimal risk of infection by exposure at this point. Thomas Walsh, the county's medical director of tuberculosis control, explained, "Most of this is just precautionary," but they are just trying to ensure that everyone who may have been exposed to the student is tested.
Alabama health officials are concerned about the rate of syphilis in Morgan County. The county recorded 37 cases of the disease last year, for a rate of 33.97 cases per 100,000 population; the statewide average is 8.1 cases per 100,000 people. The majority of the county's cases, which were mostly among Hispanic men, were detected late in 2000 as part of an outbreak in which the patients did not use protection when having sex with infected women. Joe Andrews, the disease intervention director for the state Health Department's 13 northernmost counties, noted that "unprotected sex is a focus of our education programs." January is expected to be a critical month, Andrews said, as it coincides with the end of the 21-day protection period of the penicillin treatments the patients received for syphilis and the return of many Hispanics from Mexico for the holidays. Andrews said the prevention programs will also now involve neighboring Marshall County, which has a growing Hispanic population.
Researchers concluded that given the broad range of individual family needs, each situation should be individually addressed regarding the care of HIV-infected children. A study published in the December issue of Pediatric Infectious Disease Journal (2000;19:1148-1153) detailed the percentages of medication adherence and viral loads associated with nonadherence, as well as other issues confronted by the caregivers. Researchers from the Centers for Disease Control and Prevention found that nearly 50 percent of parents or other caregivers of HIV-infected children reported that their child had missed at least one dose of medication in the past week. Many of the caregivers cited telephone access to medical assistance, a medicine that tasted better, lengthier dosing intervals, and no need for refrigeration as keys to better compliance to the HIV treatment program.
The United Nations Food and Agriculture Organization (FAO) reported on Thursday that of the 36.1 million people worldwide living with HIV, at least 95 percent of the infected people live in developing countries. The FAO said it is the rural communities within the poor nations that are most affected by the disease, as it strikes the adult population and destroys family structures and food and security levels. To make matters worse, city residents and migrant workers who become ill often return to their family homes in the villages for care, which burdens the poor even more. Health officials warn that HIV is no longer simply a health issue, it is quickly destroying agricultural and rural development that has taken many years to build.
A study published in the December issue of the Journal of Acquired Immune Deficiency Syndromes (2000;25:345-352) reported that the probability of pregnancy among HIV-positive women in three African cities was significantly reduced. The researchers studied fertility data for more than 4,000 women attending antenatal clinics in Yaounde, Cameroon; Kisumu, Kenya; and Ndola, Zambia. Based on their findings, the authors estimate reductions in the likelihood of pregnancy among HIV-infected women from 16 percent to 26 percent. The researchers note that because HIV reduces fertility, the findings may be useful in better predicting health care needs, for monitoring interventions, and for population estimates.
The European Commission (EC) has approved GlaxoSmithKline's HIV drug Trizivir for all 15 member states of the European Union (EU). The drug, which has already been approved in the United States and four other nations, combines three AIDS drugs into one pill. Those three drugs are Ziagen (abacavir), Epivir (lamivudine), and Retrovir (zidovudine). Because pricing policies vary between EU member states, a spokesperson for GlaxoSmithKline could not say whether the combination drug would cost less than taking the three medications separately; however, the company did note that the new product could increase patients' adherence to treatment regimens.
Recovering or former addicts with HIV face yet another challenge as they must decide whether or how to continue with treatments for HIV that threaten to breach their sobriety status. For example, the manufacturers of Norvir recently changed the medication from a pill to liquid form only, forcing individuals who choose to use the drug to consume a small amount of alcohol with every dose. This change has some recovering alcoholics who are also infected with HIV concerned, wondering if they will be able to stop after the required dosage. One HIV-infected man who has been sober for nearly 25 years notes that while he tries to follow the "Keep it simple" slogan of Alcoholics Anonymous, it is difficult because he is also taking high doses of a potentially addictive painkiller for his neuropathy and a drug with stimulant properties to treat his depression. Testimonials from others with HIV reflect their shared concern for such treatments, especially the possibility that they might be considered as having relapsed.
In September, 2000, the Centers for Disease Control and Prevention received two reports of life-threatening hepatotoxicity (liver damage) among health care workers taking nevirapine for post-exposure prophylaxis (PEP) after occupational exposure to HIV. Nevirapine has not been recommended for PEP use and has previously been associated with instances of serious skin conditions, liver damage, and death when used for treating HIV-infected individuals. The recent reports prompted a review of the Food and Drug Administration's registry of serious adverse events, which identified 20 other reports of serious side effects among people who had taken nevirapine for PEP. These 22 cases, in healthy, uninfected individuals who took the drug for a relatively short period of time (two weeks, on average, before onset of symptoms) are cause for serious concern. Anyone considering PEP should consult with their physician to carefully weigh the risks of HIV infection related to their exposure, the potential benefits of post-exposure therapy, and the possible side effects of any PEP regimen. Recommended regimens are outlined in "Public Health Service Guidelines for the Management of Health-Care Worker Exposures to HIV and Recommendations for Post-exposure Prophylaxis" (MMWR, Vol. 47, RR-7, May 15,1998; available online at www.cdc.gov/hiv/treatment.htm). In most circumstances, the risks associated with nevirapine as part of an occupational PEP regimen might outweigh the anticipated benefits.
This article was provided by U.S. Centers for Disease Control and Prevention. It is a part of the publication CDC HIV/Hepatitis/STD/TB Prevention News Update. Visit the CDC's website to find out more about their activities, publications and services.