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December 2002


Painful Bone Problem More Common in HIV Patients

Around 4 percent of HIV-positive patients may unknowingly have the bone disorder osteonecrosis, a potentially painful and debilitating condition, suggests new research in the July 2 issue of Annals of Internal Medicine (2002;137:17-24). Osteonecrosis is a disorder characterized by the death of bone. As bone dies, it weakens and can collapse, causing pain. The investigators, led by Dr. Joseph A. Kovacs of the National Institutes of Health, found no trace of the condition in the HIV-negative study participants.

During the study, Kovacs and his team used magnetic resonance imaging (MRI) to scan the bones of 339 adults with HIV who had no symptoms of osteonecrosis, as well as of 118 HIV-negative volunteers. Researchers found that 15 -- slightly more than 4 percent -- of the asymptomatic patients with HIV had evidence of osteonecrosis in their hipbones.

More and more doctors are now diagnosing osteonecrosis in HIV patients, Kovacs and colleagues noted. The Food and Drug Administration has been receiving a growing number of notifications of new cases of osteonecrosis in the HIV-positive population. Exactly how many people in the general US population develop osteonecrosis is not known. According to recent estimates, between 10,000 and 20,000 new US cases are diagnosed each year.

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Kovacs said that certain factors appeared to be associated with the development of osteonecrosis in HIV patients. For example, the condition seemed to appear more frequently in patients who took steroids, testosterone or blood fat-lowering drugs to treat the side effects of protease inhibitors. Kovacs stressed that these drugs may not, in fact, have induced the condition. "Whether these [drugs] are causal or not, we can't say," he said.

Previous research suggested protease inhibitors might play a role in the development of osteonecrosis. However, the current study detected no link between the two, likely because there was no comparison group -- more than 90 percent of the HIV-positive participants were taking protease inhibitors, Kovacs said.

Osteonecrosis was first diagnosed in HIV-positive patients in 1990 -- before the appearance of protease inhibitors -- but more cases are being reported now that the drugs have become more common, Kovacs noted. However, since these drugs became available people are also living much longer with HIV, which could also explain the increase in osteonecrosis. Osteonecrosis "may somehow be related to HIV infection itself," Kovacs speculated. (Reuters Health, 07.16.02, Alison McCook)


Impact of Adherence and HAART on Survival

Researchers assessed the impact of antiretroviral therapy (HAART) adherence on survival in HIV-infected patients older than 18 years of age at the Hospital del Mar in Barcelona during the period 1990 to 1999.

HIV-infected patients were given appointments to attend the hospital pharmacy to receive antiretroviral drugs every two months. The pharmacist in charge of delivering the drugs, unaware of CD4 counts or viral load, carried out the study of regimen adherence. A computer-assisted pharmacy dispensing system was used. Adherence was assessed by self-report, asking how many doses had been missed in the month before the visit, and by pharmacy appointment count. Patients were considered nonadherent if they declared that they took less than 90 percent of the total dose of antiretroviral drug(s) prescribed and/or if they failed to keep pharmacy appointments. Failure to keep pharmacy appointments and omissions in drug taking motivated by adverse events or acute illness was not considered indicative of an adherence problem. If the patient was considered nonadherent at one visit, s/he was categorized as nonadherent for this type of treatment.

Monotherapy was either zidovudine or didanosine; bitherapy was zidovudine plus didanosine or zidovudine plus zalcitabine; and triple therapy was ritonavir, indinavir and nelfinavir or ritonavir plus saquinavir in association with nucleoside analogues. Criteria for proposing ART were presenting symptomatic HIV infection or (in asymptomatic patients) two consecutive CD4 cell counts <500/mm3.

A total of 1,219 patients who initiated at least one type of ART were included. ART was monotherapy in 23.7 percent of cases, with two drugs in 30.5 percent, and triple therapy in 45.8 percent. A total of 329 patients (27 percent) switched from monotherapy or bi-therapy to highly active ART (HAART). There were 211 deaths (17.3 percent), and 133 (63 percent) of the patients who died were injection drug users (IDUs). AIDS was the immediate cause of death in 120 (90 percent) cases. Among the non-IDUs, 59 (76 percent) deaths were related to HIV infection. Just 68.2 percent of patients were considered adherent to their first therapy.

Overall probability of survival at three years was 78.6 percent. In univariate analysis, survival was significantly higher for triple therapy compared with double therapy or monotherapy and for adherents compared with nonadherents. Thus, three-year survival rates were: 93.6 percent, 77.8 percent and 76.1 percent among adherent cases with triple therapy, bi-therapy and monotherapy, respectively, whereas among nonadherent cases, the corresponding rates were 77.8 percent, 72.6 percent and 64.8 percent, respectively. Comparing adherent with nonadherent cases, three-year survival rates were 81.2 percent and 72.9 percent, respectively.

In multivariate analysis, adjusting the model for age and sex, the variables that presented significant differences with respect to mortality were clinical stage at the beginning of treatment (AIDS), CD4 lymphocyte levels, type of treatment, and adherence. Patients who initiated treatment in advanced stages, those who had CD4 counts <350cells/µL, those who had been treated with one or two drugs, and nonadherent patients all had poorer survival rates.

A nonadherent patient on triple therapy was 3.87 times more likely to die than an adherent patient on the same therapy. Furthermore, the enormous benefit associated with HAART compared with other less active forms of treatment is considerably reduced when the patient is nonadherent. Whereas the risk of dying for an adherent patient on HAART is nine times lower in comparison with the other types of treatment, this risk is only three times lower when the patient is nonadherent. The impact of HAART on mortality is difficult to assess exactly; HIV care changed between 1990-1999, and mortality may have diminished for reasons other than triple ART. However, guidelines for the use of prophylaxis for opportunistic infections and vaccinations at the center remained practically unchanged, 1990-1999. An estimated 27 percent of patients on HAART were exposed previously to suboptimal therapy in the pre-HAART era, and this could potentially result in underestimating the power of HAART.

Researchers conclude that the modifiable factors most strongly associated with survival were type of treatment and adherence. In the short term, researchers continue, it would be desirable to accompany therapy with intervention strategies intended to improve adherence. (Journal of Acquired Immune Deficiency Syndromes, 05.01.02, Vol. 30; No. 1: P. 105-110, Patricia García de Olalla et al.)


Some HIV-Positives at Greater Risk of Liver Problems

HIV-infected patients who are taking antiretroviral drugs can have a jump in liver enzymes in the blood, a sign of possible liver damage. A new study in the July 1 edition of Journal of Infectious Diseases (2002;186:23-31) suggests that women may be at greater risk than men, as are those with liver-infecting viruses, such as hepatitis B or C.

Dr. Ferdinand Wit of the Academic Medical Center in Amsterdam and colleagues studied 560 patients who began taking antiretroviral drugs between July 1996 and January 2000. In roughly a three-year period after beginning the drugs, 8 percent of patients experienced liver enzyme levels more than ten times the upper limit of normal. However, none of the patients died from complications related to the problem, the authors noted.

Those with chronic hepatitis B or C infection were at greater risk, as were female patients. Those who had never received combination antiretroviral therapy before and patients who recently began a regimen containing nevirapine or high-dose ritonavir were also at risk. At least one risk factor was present in 97 percent of patients with severely elevated liver enzymes (hepatotoxicity).

In patients with hepatitis B, discontinuing the drug lamivudine also was a risk factor for severely elevated liver enzymes. Based on this, the authors suggest that even if lamivudine-resistant HIV strains develop in these patients, continued use of the drug should be considered.

While the incidence of severely elevated liver enzymes is rather high, most cases do not cause any symptoms and resolve without requiring a change in the drug regimen, the investigators noted. However, cases involving nevirapine require careful monitoring, they said. Nevirapine "has been linked to several fatal cases of hepatotoxicity," they emphasized. (Reuters Health, 07.16.02)


Long-Term Interruption of HIV Treatment May Be Safe in Certain Patients

Interrupting HIV treatment for an extended period and then reinitiating therapy might be safe in certain patients, according to a study by Northwestern University infectious disease experts. Chad Achenbach, M.D., and coinvestigators from the Feinberg School of Medicine presented data from their research at the 14th International AIDS Conference.

In an observational study, 25 HIV-infected patients with viral suppression for at least six months while receiving highly active antiretroviral therapy (HAART) interrupted treatment for an average of nine months. None of the patients had HIV-related infections or illnesses during the interruption. All of the patients had increases in virus levels and drops in infection-fighting CD4 cells. Patients with lower virus levels prior to treatment and stronger immune systems responded more favorably during the interruption. When HAART was resumed in 11 of the patients, they experienced maximal viral suppression and robust increases in CD4 cell counts.

Previous studies have examined whether treatment interruption could be used as a strategy for boosting immune response to HIV or reducing resistance to the medications. The current study focused on the effects of stopping HAART for longer periods to minimize complications of the therapy. "We were surprised that so many patients were able to remain off their therapy for so long a period," Achenbach said.

"Extended treatment interruption appears safe and, after further study, may be an important HIV treatment strategy for the reduction of long-term toxicity, medication burden and expense," said Achenbach. He cautioned that not all patients should stop therapy, and that if patients do interrupt therapy, they should consult their physician. (AIDS Weekly, 08.26.02)


Prison Rapes Spreading Diseases

Rape has become so common in US federal and state prisons that it could have deadly consequences for the inmate population as well as the public at large, according to experts. Prison rape has been associated with the spread of diseases such as AIDS and TB.

"The AIDS incidence within prisons is alarmingly high," said Pat Nolan, president of Justice Fellowship, which works to reform the criminal justice system. He noted 95 percent of people in prison will eventually be released, so if they contract AIDS or other diseases while incarcerated they will be a tremendous burden to society. A major part of the problem is prison officials who condone rape among inmates, he said, which may be used to punish or control prisoners.

"Rape and HIV in prison is eight to ten times as high as in the general population," said Lara Stemple, executive director of Stop Prison Rape. The people most likely to be raped in prisons are nonviolent and first-time offenders: those most likely to be released into the general population and pose a disease risk, she said. AIDS, herpes and other STDs have been spread in prisons, and hepatitis C is epidemic in certain prisons, Stemple said. One in five men have been sexually assaulted in prison, and one in ten have been raped. Among women inmates, the rate of sexual abuse can be as high as 27 percent in some prisons, and some inmates have become pregnant after being raped by prison guards.

In June, bi-partisan legislation called the Prison Rape Reduction Act was introduced in both the Senate and the House. It would establish a national commission to set standards for reducing and eliminating prison rape. Federal prisons would have to adopt these standards and state prisons could only opt out of them if their state legislature votes not to participate. The Justice Department would be required to conduct an annual review of prison rape to determine where the incidence is unusually high. States with prisons within the worst third would have to explain their situation before a review panel. (Washington Times, 07.26.02, United Press International)


Online Access to Risky Sex

Gay and bisexual men looking for quick sex increasingly are turning to the Internet, and they are doing so at far greater rates than their heterosexual counterparts. As a result, public health experts say, they are speeding the spread of HIV and other STDs.

The same accessibility and anonymity that make the Web so popular also make it dangerous to sex-seeking users, multiplying "the probability of high-risk people meeting high-risk people," said Colorado epidemiologist John Potterat. Sex-oriented chat rooms could become "the eBay of homosexual sex," he said.

Officials have no means of systematically monitoring the sites. "We are not keeping up," said Peter Kerndt, director of STD control for Los Angeles County. Worse than that, "we have little sense of what approaches would be effective." The numbers are large, according to Gay.com. Over 150,000 members sign on to the chat rooms every day.

In California, Colorado, Kentucky, Maine, and other states, public health officials have tracked outbreaks of STDs to chat room meetings. In San Francisco, 18 percent of the gay and bisexual men diagnosed with early forms of syphilis last year said they had found sex partners on the Internet. In Los Angeles County, the figure was 13 percent.

With the help of disease investigators in 1999, Dr. Jeffrey Klausner, San Francisco's STD controller, linked seven men's syphilis infections to an overlapping network of 99 recent sexual partners. One of the infected men had 47 partners. Staff and volunteers spent hours on AOL's chat rooms alerting users to the outbreak. In the end, fewer than half of the seven men's sexual partners were notified and tested because there is no way of actually identifying a user who uses an online screen name and changes it regularly. Internet providers won't release the real identities of users except by court order. Today, the San Francisco Health Department pays Gay.com to run banner advertisements in its West Coast chat rooms and arranges for Klausner to answer user's questions. (Los Angeles Times, 07.26.02, Charles Ornstein)


Researchers Document Rare Case of Second HIV Infection With Different Strain

Swiss researchers have documented a rare case of a patient contracting a second HIV infection two years later with a different strain of the virus. The researchers said the case could have implications for the development of an AIDS vaccine, and its occurrence strongly supports the practice of safe sex for those already infected with HIV.

Dr. Bernard Hirschel of the University of Geneva, one of the researchers, said they were able to document the case because the patient was enrolled in an AIDS drug study to test early treatment of the virus. Successfully treated for over two years, the patient was taken off the drugs when he received an experimental vaccine intended to boost his immune system. Months later in April 2001, and weeks after he had unprotected sex with men, his virus level increased sharply and he was found to be infected with a different strain of HIV. The research, with an accompanying editorial, is published in Thursday's New England Journal of Medicine (Vol. 347, No. 10, P. 731-736; with editorial at P. 756-758).

"It just shows how little we understand what's happening with HIV-related immunity," said Hirschel. Doctors have long assumed that a patient's natural immunity would keep them from getting HIV more than once. A similar Boston case was reported by Dr. Bruce D. Walker at the Barcelona AIDS conference; last month a report on two cases in injection-drug users in Thailand was published. According to an editorial by Walker and Dr. Philip J.R. Goulder of Massachusetts General Hospital, the Swiss report provides "convincing evidence that HIV-1 superinfection can occur long after an initial infection is established."

"With sexual activity seemingly increasing among persons with HIV-1 infection, this is a public health message that needs to be broadcast loud and clear," they wrote. Walker added that vaccines are already being developed for geographic areas and that researchers anticipate that one vaccine may not protect against all strains. He noted that variations in HIV are greater than those in the flu virus, which requires a new vaccine every year. (Associated Press, 09.05.02, Stephanie Nano)


Dozens Test Positive for TB in Marcy, NY Prisons

Prison union officials warned of a "tuberculosis outbreak" at the Marcy Correctional Facility in Marcy, N.Y., after 18 inmates were diagnosed with active tuberculosis. Dozens of others tested positive for infection, including two guards, according to Peggy Porter, health and safety coordinator for the New York State Correction Officers and Police Benevolent Association, which represents 24,000 officers.

James Flateau, spokesperson for the state Department of Correctional Services, confirmed that 37 inmates and two officers tested positive for exposure to TB, but emphasized that 90 percent of people exposed do not develop TB. State inmates and staff are tested yearly for TB exposure, Flateau said. "The annual testing and monitoring exceed that which is afforded the general public ... for the protection of our staff," he said.

According to Flateau, inmates with positive results are sent to isolation rooms until cases can be confirmed and their contacts tested. There are only four or five isolation units in each prison. He pointed out that the rate of active TB cases in the state's prisons fell from 124 per 100,000 inmates in 1995 to 25 cases per 100,000 inmates last year.

Anthony Farda, the union's central region vice president, however, considered the situation "a very serious health concern for our union and for all of our officers." Marcy, 44 miles east of Syracuse, is a medium-security prison housing more than 1,500 inmates and 350 guards. (Associated Press, 09.12.02)





  
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This article was provided by Body Positive. It is a part of the publication Body Positive.
 

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