Efficacy and safety of TMC114/ritonavir in treatment-experienced HIV patients: 24-week results of POWER 1

BACKGROUND

The ongoing phase IIb POWER 1 (TMC114-C213) trial is designed to assess efficacy and safety of the protease inhibitor (PI) TMC114 (darunavir) in treatment-experienced HIV-1-infected patients.

DESIGN

This randomized, partially blinded, 24-week dose-finding study compared efficacy and safety of four doses of TMC114 plus low-dose ritonavir (TMC114/r) with investigator-selected control PI(s) (CPI[s]).

METHODS

Patients with one or more primary PI mutation and HIV RNA > 1000 copies/ml received optimized background therapy, plus TMC114/r 400/100 mg once daily, 800/100 mg once daily, 400/100 mg twice daily or 600/100 mg twice daily, or CPI(s). The primary endpoint (intent-to-treat) compared proportions of patients achieving viral load reduction >or= 1.0 log10 copies/ml from baseline.

RESULTS

In total, 318 patients were treated. Baseline mean viral load was 4.48 log10 copies/ml; median CD4 cell count was 179 cells/microl. In the CPI arm 62% of patients discontinued (virological failure: 54%); 10% of TMC114/r patients discontinued. More TMC114/r (69-77%) than CPI patients (25%) reached the primary endpoint (P < 0.001); 43-53% of TMC114/r patients and 18% of the CPI arm achieved viral load < 50 copies/ml (P < 0.001). TMC114/r demonstrated greater mean CD4 cell count increases versus CPI(s) (68-124 versus 20 cells/microl; P < 0.05). TMC114/r 600/100 mg twice daily demonstrated the highest virological and immunological responses. Adverse event incidence was similar between treatments; headache and diarrhoea were more common with CPI(s).

CONCLUSIONS

TMC114/r demonstrated statistically higher 24-week virological response rates and CD4 cell count increases than CPI(s). TMC114/r 600/100 mg twice daily has received regulatory approval in treatment-experienced patients.

Combination of tenofovir and lamivudine versus tenofovir after lamivudine failure for therapy of hepatitis B in HIV-coinfection

OBJECTIVE

At present sequential monotherapy for chronic hepatitis B with hepatitis B virus (HBV)-polymerase inhibitors is clinical practice. It is unknown to date whether combination therapy with lamivudine plus tenofovir could be superior to sequential therapy with tenofovir after the occurrence of lamivudine resistance.

METHODS

We conducted a multicenter, 1: 2 matched pair analysis comparing patients with HBV/HIV-coinfection starting an antiretroviral regimen including tenofovir plus lamivudine with patients who had highly replicative, lamivudine resistant HBe-antigen positive chronic hepatitis B and started with tenofovir as the only active HBV polymerase inhibitor subsequent to lamivudine.

RESULTS

At baseline patients on tenofovir plus lamivudine (n = 25) had a median HBV DNA of 5.9 x 10(7) copies/ml compared to 1.37 x 10(8) copies/ml in the tenofovir arm (n = 50; P = 0.32). A sustained undetectable HBV DNA < 1000 copies/ml was achieved in 19/25 (76%) patients on tenofovir plus lamivudine and in 42/50 (84%) on tenofovir (P = 0.53). A loss of HBe-antigen was observed in 9/25 (36%) patients on tenofovir plus lamivudine and in 12/50 (24%) patients on tenofovir (P = 0.29). HBs-antigen loss was found in 1/25 (4%) and 3/50 (6%) patients.

CONCLUSIONS

In this cohort of HBV/HIV-coinfected individuals, full HBV DNA suppression was achieved in the majority of patients independent of treatment allocation. Loss of HBe- and HBs-antigen was not different between the two study arms. Over a median treatment period of 116 weeks tenofovir was as effective as tenofovir plus lamivudine. Longer treatment periods may be needed to evaluate potential benefits of first-line combination therapy for chronic hepatitis B.

AIDS-related B-cell lymphoma (ARL): correlation of prognosis with differentiation profiles assessed by immunophenotyping

This study was undertaken to analyze the differentiation profiles assessed by immunophenotyping in AIDS-related B-cell lymphoma (ARL) and their relation to the clinical course. Paraffin-embedded sections of 89 ARL cases during 1989 to 2004 were stained immunohistochemically with antibodies to CD3, CD10, CD20, CD38, CD138/Syndecan-1 (Syn-1), multiple myeloma-1/interferon regulatory factor-4 (MUM1/IRF4), B-cell lymphoma protein-2 (BCL-2), BCL-6, latent membrane protein-1 (LMP-1), and Ki-67. Expression of CD10 and CD20 were associated with better overall survival (OS; P = .009 and P = .04, respectively). Expression of CD20 was associated with longer disease-free survival (DFS; P = .03), whereas expression of CD138/Syn-1 was associated with shorter DFS (P = .03). OS and DFS were worse in patients with immunophenotypic profiles related to post-germinal center (GC) differentiation (BCL-6 and CD10 negative, MUM1/IRF4 and/or CD138/Syn-1 positive) when compared with GC differentiation (P = .01). When controlled for age-adjusted International Prognostic Index (IPI), prior AIDS-defining illness (ADI), and year of ARL diagnosis, a post-GC differentiation remained significantly associated with poor OS and DFS. Expression of CD10 was associated with a preserved immunocompetence, whereas CD20 was less frequent in patients developing ARL while on highly active antiretroviral therapy (P = .04). In summary, lack of CD20 or CD10 expression and a post-germinal center signature are associated with a worse prognosis in ARL.

[Dramatic increase in lymphogranuloma venereum among homosexual men in Hamburg]

Classical sexually transmitted diseases, including syphilis and gonorrhea, have recently increased significantly among homosexual men in Hamburg. During the last year we also observed an increase in patients with lymphogranuloma venereum (LGV) at the ifi-institute in Hamburg. In 2003, we identified 4 homosexual patients with LGV in different clinical stages. None of the patients has traveled outside Germany. Three of these patients were HIV-infected. In all cases Chlamydia trachomatis was identified by SDA (strand displacement amplification) in genital swabs or lymph node aspirates. In three cases sequencing of ompA PCR products was performed and in each instance revealed the C. trachomatis serovar L2. Other important genital pathogens were excluded by specific PCR tests, bacteriological and serological tests. LGV should be included in the differential diagnosis of anogenital and oral erosions, especially in homosexual patients and HIV-infected patients. Novel nucleic acid amplification tests can be used for the rapid and reliable diagnosis of LGV by identifying Chlamydia trachomatis.

Four cases of lymphogranuloma venereum in Hamburg, 2003

In the course of 2003, four men were diagnosed with lymphogranuloma venereum (LGV) at the Hamburg Institut für interdiziplinäre Infektiologie und Immunologie. All were men who have sex with men (MSM).

Epidemiology of HHV-8 infection in HIV-positive patients with and without Kaposi sarcoma: diagnostic relevance of serology and PCR

BACKGROUND

Kaposi's sarcoma (KS) remains the most common neoplasm in HIV-infected patients. Human herpesvirus 8 (HHV-8) infection is etiologically associated with KS. Diagnostic procedures with regard to HHV-8 infection are not routinely performed in HIV-infected patients; diagnostic and prognostic value of HHV-8 serology or PCR are unknown in this setting. Epidemiological data concerning HHV-8 infection of HIV-infected patients in Germany are rare.

OBJECTIVES

To assess prevalence of HHV-8 infection in a cohort of HIV-infected patients with and without KS in Germany and to correlate this to manifestations and clinical course of KS.

STUDY DESIGN

HHV-8 serology was performed in 483 patients in routine care for HIV-infection in northern Germany. HHV-8 DNA was analyzed by PCR in peripheral blood mononuclear cells (PBMC) of 293 patients; in a subgroup multiple samples were analyzed. History and manifestations of KS were recorded.

RESULTS

HHV-8 antibodies were detected using IFT in 91% of 33 patients with KS and 52% of 398 patients without KS. In 36 of 293 (12.3%) patients HHV-8 DNA was detected in PBMC. In general, HHV-8 DNA was not continuously detected when multiple samples from the same patient were analyzed. Patients with KS history were more likely to be PCR positive than those without (45.5% versus 7.8%). In patients with active KS HHV-8 DNA was detected more frequently than in patients with disease remission. HHV-8 DNA was not detected in serologically negative patients. However, three patients with KS history in full remission for several years were seronegative.

CONCLUSIONS

HIV-infected patients were frequently found to be positive for HHV-8 antibodies. The number of patients positive for viral DNA in PBMC was much smaller. Single PCR-examinations were of little value for prognosis, but repeated detection of HHV-8 DNA represents an increased risk of disease activity.

Strong impact of highly active antiretroviral therapy on survival in patients with human immunodeficiency virus-associated Hodgkin's disease

Hodgkin's disease (HD) is the most common non-acquired immunodeficiency syndrome (AIDS)-defining malignancy in human immunodeficiency virus (HIV)-infected patients. We analysed the outcome of patients with HIV-associated HD (HIV-HD) with respect to the use and efficacy of highly active antiretroviral therapy (HAART) and other prognostic factors. To evaluate the effects of several variables on overall survival (OS), Kaplan-Meier statistics and extended Cox regression analysis were performed. Response to HAART was used as a time-dependent variable and was defined as an increase of >0.1 x 10(9) CD4 cells/l and/or at least one viral load <500 copies/ml during the first 2 years following diagnosis of HIV-HD. Fifty-seven patients with HIV-HD diagnosed between 1990 and 2002 were included in the study. In the Cox model, the only factors independently associated with OS were HAART response [relative hazard (RH) 0.19; 95% confidence interval (CI) 0.06-0.60], complete remission (RH 0.30, 95% CI 0.13-0.72), and age <or=45 years (RH 0.23; 95% CI 0.09-0.60). Median survival time in patients without HAART response was 18.6 months, whereas the median survival time in patients with HAART response was not reached (89% OS at 24 months). In this cohort, a significant improvement in survival was found in patients with HIV-HD who responded to HAART.

Response to highly active antiretroviral therapy strongly predicts outcome in patients with AIDS-related lymphoma

BACKGROUND

AIDS-related lymphoma (ARL) remains a frequent complication of HIV infection. We analyzed the outcome of patients with ARL with respect to the use and efficacy of highly active antiretroviral therapy (HAART) and to potential prognostic factors.

METHODS

This multicenter cohort study included patients with systemic ARL diagnosed between 1990-2001. We evaluated overall survival and the effects of several variables on overall survival using the Kaplan-Meier method and the extended Cox proportional hazards model. Response to HAART was used as a time-dependent variable and was defined as a CD4 cell count increase of >/= 100 x 106 cells/l and/or at least one viral load < 500 copies/ml during the first 2 years following diagnosis of ARL.

RESULTS

Among 203 patients with ARL, median overall survival was 9.0 months [95% confidence interval (CI), 7.6-12.4 months]. In the univariate analyses, age < 60 years, no previous AIDS, CD4 cell counts >/= 200 x 106 cells/l, hemoglobin > 11 g/dl, Ann Arbor stages I-II and A, no extranodal lesion, response to HAART, and complete remission showed statistically significant association with prolonged overall survival. In the multivariate Cox model, the only factors independently associated with overall survival were response to HAART [relative hazard (RH), 0.32; 95% CI, 0.16-0.62], complete remission (RH, 0.24; 95% CI, 0.15-0.36), previous AIDS (RH, 1.92; 95%CI, 1.23-3.01) and extranodal involvement (RH, 2.85; 95% CI, 1.47-5.51).

CONCLUSIONS

Efficacy of HAART was independently associated with prolonged survival in this large cohort of patients with ARL. Information on patient's response to HAART is crucial for the evaluation of future treatment strategies.

Remission of a cutaneous Mycosis fungoides after topical 5-ALA sensitisation and photodynamic therapy in a patient with advanced HIV-infection

BACKGROUND

Treatment of Mycosis fungoides (MF) in HIV-infected patients is controversially discoursed. Photodynamic therapy (PDT) after topical sensitization with 5-aminolevulinic acid (5-ALA) is a new and effective modality for treatment of skin malignancies.

OBJECTIVE

In this report we describe, what is, to our knowledge, the first case of a patient with MF through advanced HIV-infection, successfully experiencing topical 5-ALA sensitization and PDT.

METHODS

5-ALA ointment was applied to plaques and held in occlusion for 4 hours. PDT was applied using the PDT 1200 irradiation source (Waldmann Medizintechnik System) with 180 J/cm superset 2.

RESULTS

Complete remission of MF was achieved, after two completed cycles of photodynamic therapy.

CONCLUSION

MF lesions in the presended case showed a high response to 5-ALA sensitization and PDT. This modality appeared to be very effective in treatment of MF in a HIV-infected patient and could be a valuable treatment option for cutaneous T-cell lymphoma in HIV-infected patients.

Radata - implementation of resistance analysis and expert advice for optimized HAART switches in general practice of HIV-infected individuals via a compiling internet presence

BACKGROUND

HIV-infected patients fail viral load suppression, because resistance against antiretroviral drugs arises or for other reasons. HIV-resistance analyses can aid to achieve effective HAART regimen. Furthermore, clinical benefits from genotyping in study settings are significantly higher for treating physicians, who can include external advice from HIV-experts into HAART switch.

OBJECTIVE

To develop a compiling internet presence to provide expert advice for HAART switch in general practice of HIV-infected individuals after therapy failure. -

DESIGN

A multifactorial (genotyping, drug monitoring, adherence, expert advice) interdisciplinary internet service (www.radata.de) with an associated server hosted database.

PATIENTS AND METHODS

HIV-infected patients after failure to HAART are eligible for registration to the Radata project. Genotyping is performed according to protocols specific for each participating institution. Therapeutic drug monitoring (NNRTIs, PIs) follows setting for drug level detection by mass spectrometry. An adherence self-report is completed by every patient. Clinical documentation is provided by the treating Primary Care Physician. Clinical expert advice for implementation into HAART switch in daily clinical practice for treating physicians is provided by HIV-experts according to data obtained. Clinical and laboratory follow-up visits are scheduled firstly 4 weeks after HAART switch and three monthly afterwards, over a period of one year.

RESULTS

Technical resources and a compiling internet presence for generation of resistance analysis based expert advice were developed. Initially, 7 HIV-treatment centres, 7 laboratories and 17 HIV advisors contribute to Radata database project. 15 patients were enrolled during test period. 30 expert advices were generated during the test phase. Expert advice was provided in 6 weeks median for implementation into HAART switch. 13 out of 15 expert advices were implemented into HAART switch by treating Primary Care Physicians.

CONCLUSIONS

Radata is a novel database concept with features to generate expert advice for implementation into HAART switch of HIV-infected subjects. A test period has shown, that the concept is technically approved to fit all requirements with regard to data collection, evaluation and to generate expert advice for therapy switch in daily clinical practice.

HHV-8 DNA in blood and the development of HIV-associated Kaposi's sarcoma in the era of HAART--a prospective evaluation

OBJECTIVE

To explore the significance of HHV-8 viremia in HIV-positive individuals for the risk of developing Kaposi's sarcoma (KS) in the era of highly active antiretroviral therapy.

METHODS

237 HIV-positive patients were included in this prospective evaluation and followed over an average duration of 34 months. HHV-8 DNA in peripheral blood mononuclear cells (PBMCs) and CD4-lymphocytes were determined. In addition AIDS-defining conditions and antiretroviral therapy were documented of all participating subjects.

RESULTS

HHV-8 DNA was detectable in PBMCs of 12.6% out of all individuals. 53.3% of these patients initially complained about KS, although 9.2% of patients without HHV-8 DNA in PBMCs were found on KS as well. Furthermore, four patients in total were observed with newly developed KS during follow up visits. None of these patients were noted with detectable HHV-8 DNA at their initial evaluation.

CONCLUSIONS

Prevalence of HHV-8 DNA in PBMCs of subjects in this investigation was quite similar to former investigations. However, new diagnosed KS occurred less frequently than demonstrated in previous studies. All of those observed patients with new KS manifestations were negative for HHV-8 DNA in PBMCs at study entry. This observation differs from earlier studies which have postulated the detection of HHV-8 DNA in PBMCs as a predictive value for development of KS. Due to results as presented, a single HHV-8 DNA test in blood has no predictive value in support of predictability of KS development. With respect toto costs and to a less complicated performance antibody assays should be preferred.

Remission of cutaneous Mycobacterium haemophilum infection as a result of antiretroviral therapy in a Human Immunodeficiency Virus--infected patient

We describe the first Mycobacterium haemophilum infection that occurred in a patient with human immunodeficiency virus in Germany and report 7 newly diagnosed cases of M. haemophilum infection. In the former case, a local M. haemophilum skin infection resolved as a result of successful antiretroviral therapy only; however, that clinical outcome may not be possible for more invasive forms of the disease.

Reappearance of HIV multidrug-resistance in plasma and circulating lymphocytes after reintroduction of antiretroviral therapy

BACKGROUND

After the discontinuation of antiretroviral therapy in HIV-infected patients with highly resistant virus, the detectability of viral resistance mutations quickly decreases. To which extent this represents a true loss of resistance or rather a detectability phenomenon remains unclear.

OBJECTIVES

To monitor virologic response and resistance pattern during a non-strategic treatment interruption in the presence of highly drug-resistant viral strains.

STUDY DESIGN

We performed serial genotypic resistance analyses on viral DNA isolated from a patient with a multidrug-resistant human immunodeficiency virus infection who discontinued and later on reintroduced antiretroviral therapy. Sequencing was performed on viral DNA from plasma as well as DNA from circulating leukocytes.

RESULTS

While under combination antiretroviral therapy with two nucleosidic reverse transcriptase inhibitors, a non-nucleosidic reverse transcriptase inhibitor and a protease inhibitor, the viral load of the patient was around five logs. Genotypic resistance to all available agents was detected during this time. Antiretroviral therapy was then interrupted, and 14 weeks later an almost complete reversion of the virus to wild type was observed. After introduction of a new antiretroviral therapy regimen, the reappearance of nearly all of the formerly present resistance mutations had to be noted within 6 weeks, including mutations without known relation to any of the drugs in the new regimen.

CONCLUSIONS

We obviously observed not the de novo appearance of a complex resistance pattern under just 6 weeks of potent antiretroviral therapy, but a reappearing archival strain of the virus. This finding provides evidence for subdetectable persistence of resistant variants during treatment interruptions. Therefore, resistance analyses from peripheral blood performed in times of treatment interruptions should be interpreted with caution as they may provide incomplete information about the resistance profile soon after reintroduction of therapy.

Monitoring of endogenous interferon-alpha and human herpesvirus 8 in HIV-infected patients with Kaposi's sarcoma

The incidence of AIDS-associated Kaposi's sarcoma has declined since the mid-nineties due to the availability of potent antiretroviral therapy including protease inhibitors. However, Kaposi's sarcoma is still the most common neoplasia in HIV-infected patients. In the pathogenesis of the HIV-associated as well as other forms of this disease an infectious agent seems to play a role, namely the human herpesvirus 8. Even before the discovery of the HIV virus, high levels of an unusual acid-labile form of endogenous interferon alpha were found in patients with AIDS-associated KS. The administration of recombinant interferon alpha evolved as standard therapy for Kaposi's sarcoma in HIV-infected patients with a moderate immunodeficiency in addition to antiretroviral therapy. This investigation monitored the levels of HHV 8 and endogenous interferon in 4 patients with and without Kaposi's sarcoma during the course of HIV-disease. The results of our experiments lead us to two hypotheses: First of all, the pre-therapeutic level of endogenous interferon may be a predictor of the response to an interferon-alpha therapy for HIV-associated Kaposi's sarcoma. Secondly, the determination of HHV 8 DNA in blood of HIV-positive patients may allow conclusions about the risk for the development of Kaposi's sarcoma. However these hypotheses should be tested by monitoring the levels of endogenous interferon and HHV 8 DNA in clinical studies of a greater number of HIV-infected patients.

Resistance analyses in HIV infected patients with a history of multiple antiretroviral treatment regimens

OBJECTIVE

To assess HIV-1 isolate based resistance profiles from extensively pretreated patients and effects of a resistance guided switch of antiretroviral therapy.

METHODS

In a prospective study phenotypic and genotypic resistance analyses were performed on HIV infected individuals with failure of the current therapy and history of at least three antiretroviral regimens. Antiretroviral therapy was changed according to the results. Viral load and CD4 lymphocyte counts were measured at baseline, after 10 (SD 2), and 24 (2) weeks.

RESULTS

All patients (n=52) failed their actual regimen. Currently versus ever previously taking the specific drug, resistance associated mutations and phenotypic resistance to AZT and 3TC were found in over 80% of individuals; resistance to DDI and D4T was detected in less than 10% of cases. A resistance guided switch of therapy was followed by a median decrease of viral load of 0.5 log10 units after 24 weeks. Individuals resistant to two or more drugs compared with patients with resistance to less than two drugs of ongoing treatment, were switched to a regimen containing DDI, D4T, and a PI or NNRTI. After 10 (SD 2) weeks viral load decrease was pronounced in patients with resistance to at least two drugs in the previous regimen.

CONCLUSIONS

Among different RTI, the profile of clinically relevant resistance indicates pronounced differences when looking at separate drugs. Regarding virological response, in the context of available drugs, resistance tested with currently used methods is of limited value in extensively pretreated patients and seems to have its value primarily in first or second switch of therapy.

Survival of AIDS patients with primary central nervous system lymphoma is dramatically improved by HAART-induced immune recovery

OBJECTIVE

To evaluate the impact of immune recovery induced by highly active antiretroviral therapy (HAART) on the survival of AIDS patients with primary central nervous system lymphoma (PCNSL).

METHODS

In a multicentric retrospective analysis, 29 HIV-infected patients with histologically confirmed PCNSL were identified. To evaluate median survival, Kaplan-Meier statistics were used. To explore the effects of different variables on survival, a Weibull accelerated failure time regression analysis was performed.

RESULTS

Median age at manifestation of PCNSL was 39.1 years and median CD4 cell count was 11 x 10(6) cells/l. Seventy per cent of the patients had had a prior AIDS-defining illness. Cranial radiation (CR) was given to 12 out of 29 patients. Six patients were treated with HAART. Survival time of these patients and of the patients treated with CR alone differed significantly from those receiving neither CR nor HAART (median Kaplan-Meier survival estimate: 1093, 132, and 33 days, respectively). In the multivariate regression model, HAART and CR were identified as the only variables independently associated with prolonged survival. HAART versus no HAART and CR versus no CR increased the time to event by a factor of 6.1 (95% confidence interval, 2.4-16.0; P = 0.0002) and 3.1 (95% confidence interval, 1.5-6.3; P = 0.002), respectively. Four out of six patients on HAART showed a marked immune recovery and survived for more than 1.5 years, with two patients still alive.

CONCLUSION

Data from this cohort indicate that immune recovery induced by HAART leads to dramatic improvement in survival of patients with AIDS-associated PCNSL. These findings may have important implications for future treatment strategies.

Bacillary angiomatosis in HIV-infected patients--an epidemiological and clinical study

BACKGROUND

No data were available on the epidemiological and clinical characteristics of bacillary angiomatosis (BA) in Germany.

OBJECTIVE

To determine epidemiological and clinical data on HIV-associated BA.

METHODS

A chart review of all BA cases between 1990 and 1998 was performed in 23 German AIDS treatment units.

RESULTS

A total of 21 cases of BA was diagnosed. During this period, the participating HIV centers treated about 17,000 HIV-infected patients. As a result, a BA prevalence of 1.2 cases/1,000 patients can be assumed. 19 BA were localized in the skin; in 5 cases bones and in 4 cases the liver were involved. Out of 20 patients who received antibiotic therapy, 13 had complete remission. The median time of duration up to complete remission was 32 days (9-82). During the follow-up of the 20 patients, 7 relapses were observed.

CONCLUSION

BA is a rare HIV-associated disease with a prevalence of 1,2 cases/1,000 patients in the presented study.

In vivo dynamics and pathogenicity of wild-type and resistant Hepatitis B virus during long-term lamivudine monotherapy - a clinical note

BACKGROUND

Genotypic resistance of Hepatitis B virus (HBV) against lamivudine evolves within months after onset of therapy.

OBJECTIVES

To determine the longitudinal order in which resistance mutations appear and to compare the kinetics and pathogenicity of wild-type and resistant HBV.

STUDY DESIGN

In a longitudinal study, consecutive samples were drawn over a period of 28 months from a patient with chronic hepatitis B, and resistance mutations were followed by sequencing a part of the polymerase region of HBV. These data were compared with HBV copy numbers, HBsAg and ALT levels, and results of consecutive liver biopsies.

RESULTS

After 21 weeks of treatment, a silent mutation at codon 528 (CTG to TTG) occurred. Significant genotypic resistance was detectable after 68 weeks, indicated by a substitution of isoleucine for methionine at residue 552 (M552I). Nineteen weeks later, the virus exhibited additional resistance-associated mutations (L528M and I552V). The resulting high-level resistance was reflected by an increase of serum HBV copies of 4.7 log(10). The turnover of wild-type and resistant HBV was 2.6x10(6) and 1.8x10(6) virions/day, respectively. HBsAg and ALT levels were lower within the period when resistant HBV was detectable. During treatment the progress of liver fibrosis was arrested.

CONCLUSIONS

The in vivo replicative capacities and dynamics of wild-type and resistant HBV were similar. However, resistant HBV seemed to exhibit reduced pathogenicity.

Efficacy, safety and toleration of fluconazole suppositories in the treatment of oral candidosis

An open multicentre, non-comparative study was conducted in three countries to investigate the efficacy, safety and tolerance of fluconazole suppositories in the treatment of oropharyngeal candidosis. Patients received fluconazole 100 mg day-1 in the form of suppositories or capsules. Minimum duration of total treatment was 7 days, maximum total treatment duration was 14 days, and median duration of total treatment was 9.5 (7-14) days. After having received suppository-based treatment for at least 5 days, patients could be switched to oral treatment. Eighty-two male and 19 female patients with a mean age of 43 years were enrolled in the study. The median duration of suppository treatment was 8.9 (5-14) days. Patients were evaluated clinically and mycologically at regular intervals during and at the end of treatment. Seventy-nine of 101 patients enrolled in the study were considered efficacy-evaluable. Clinical cure was achieved in 75 of 79 (95%) patients and improvement was seen in four of 79 (5%) at the end of therapy. At follow-up after 1 month, clinical cure was observed in 48 of 63 (76%) patients. The results of this study demonstrates that the fluconazole suppository formulation is effective, safe and well tolerated.

Pneumocystis carinii pneumonia in the Federal Republic of Germany in the era of changing antiretroviral therapy - IDKF 13 -. German AIDS Study Group (GASG/IdKF)

BACKGROUND

Pneumocystis carinii pneumonia (PCP) is one of the most common AIDS defining diagnoses.

METHODS

In a prospective observational trial all cases of Pneumocystis carinii pneumonia (PCP) were evaluated. Patients with and without PCP-prophylaxis were compared for symptoms, efficacy, side effects and mortality at week 4 and 26.

RESULTS

293 patients developed a PCP episode. Patients with no prophylaxis had a significant lower CD4 cell count and a more severe clinical status at time of diagnosis. This was pronounced in the group with first positive HIV test at time of diagnosis. There was no difference in the rate of successful treatment between both groups. At week four a tendency to a better survival in the group with prophylaxis was observed, however this changed to a trend to a better survival at week 26 for the group without prophylaxis.

CONCLUSION

Even in the era of highly active antiretroviral treatment many patients present with PCP. Nearly 60% of patients presented without antiretroviral treatment or PCP-prophylaxis. Nearly 25% of all patients had their first HIV-test at time of PCP diagnosis.

Highly active antiretroviral therapy significantly improves the prognosis of patients with HIV-associated progressive multifocal leukoencephalopathy

OBJECTIVE

To evaluate the impact of different antiretroviral therapies on the prognosis of AIDS patients affected by progressive multifocal leukoencephalopathy (PML).

METHODS

A retrospective analysis of all HIV-infected patients admitted to hospital between 1988 and 1996 found 29 patients (25 men) with histologically or PCR-confirmed PML. Their mean age was 39.3 years. The median CD4 cell count was 40 x 10(6)/l (mean, 106 x 10(6)/l). Six patients had CD4 cell counts > 200 x 10(6)/l. Fourteen patients never received or stopped antiretroviral therapy following diagnosis (group A), 10 patients were treated with nucleoside analogues alone (group B), and five patients started highly active antiretroviral therapy (HAART) including protease inhibitors (group C).

RESULTS

The median survival following the onset of symptoms was 131 days, but differed significantly between the three groups: group A, 127 days; group B, 123 days; group C, > 500 days (P < 0.0002 for the difference between group C versus group A and B, stratified log-rank test). As of July 1997, four out of five patients on HAART were still alive 391, 500, 543, and 589 days after diagnosis of PML and have either experienced a resolution of the symptoms (three patients) or had progressed very slowly (one patient). A multivariate analysis using Cox regression found younger age at diagnosis to be the only other variable associated with improved survival (P < 0.02). CD4 cell count, gender, prior AIDS diagnosis, mode of HIV transmission, and therapy with foscarnet, cytarabine, or interferon-alpha did not affect survival in this cohort (P > 0.1).

CONCLUSION

This study of a large cohort of patients with confirmed PML indicates that AIDS patients with PML may benefit significantly from HAART. All patients with PML should be offered optimal antiretroviral combination therapy.

Patterns of mycobacterium avium culture and PCR positivity in immunodeficient HIV-infected patients: progression from localized to systematic disease, German Aids Study Group (GASG/IDKF)

Our aim was to establish the frequency and the longitudinal pattern of MAC culture positivity in late stage HIV-infected patients. Two other aims were to analyse risk factors for progression from localized to systemic disease and the value of PCR diagnosis using blood specimens. A total of 107 patients were recruited to be followed for 32 weeks. Prior MAC treatment and CD4 > 100/microliters were exclusion criteria. A total of 56 patients showed M. avium in at least 1 culture. 10/37 patients with MAC detected by culture first in 'non-sterile' specimens (stool, sputum) and urine progressed to systemic disease as determined by positive blood culture. Risk factors associated with this progression were a high symptom score at baseline, lymphadenopathy, anaemia, and low platelets. PCR was less sensitive than culture in detection of M. avium in blood specimens: Only 7/29 patients with positive blood cultures had a positive PCR at the same time. We conclude that symptomatic patients with advanced HIV-infection have a high frequency of MAC detection. Progression from localized to systemic culture positivity is associated with risk factors. Early 'pre-emptive' therapy is discussed.

Increased risk for opportunistic infections during chemotherapy in HIV-infected patients with Kaposi's sarcoma

BACKGROUND

Kaposi's sarcoma (KS) is the most frequent neoplasm in patients with AIDS, responsible for death in about 20-30% of the affected patients.

OBJECTIVE

To determine the frequency of opportunistic infections (OI) and change of CD4+ cell counts in patients with KS treated with chemotherapy compared to a group of matched-pair patients without chemotherapy.

METHODS

In a prospective study, the clinical courses of 35 HIV-infected patients with KS treated with chemotherapy were compared with 35 matched-pair patients without chemotherapy.

RESULTS

During the observation period of 6 months, 11 OI occurred in 10 patients of the chemotherapy group and 5 OI in 5 patients of the control group. With respect to the changes of CD4+ cell counts, no significant differences could be observed.

CONCLUSION

The risk for OI in HIV-infected patients with KS is increased while receiving chemotherapy. This should be reflected upon when chemotherapy is taken into consideration.

Foscarnet 5 versus 7 days a week treatment for severe gastrointestinal CMV disease in HIV-infected patients

In a randomized open trial foscarnet 90 mg/kg b.i.d. 5 days for 3 weeks was compared to 90 mg/kg b.i.d. daily in severe gastrointestinal cytomegalovirus disease in HIV-infected patients. Thirty-eight patients were randomized, 36 were evaluable (all male, age 24-54 years, median 40 years; CD4/microliter 0-150, median 10). Treatment efficacy was evaluated based on a score consisting of symptoms, endoscopic and histologic examination. In the 5-day treatment group 10/16 (62%) patients responded to treatment, in the 7-day treatment group 13/20 (65%), with symptoms resolving in most patients after 1 week. Side effects and adverse events were seen in 13 patients in the 5-day treatment group and in 15 patients in the 7-day treatment group. Laboratory abnormalities were common in both groups, in one patient reversible renal insufficiency developed. Efficacy and safety of treatment 5 days a week was comparable to the standard regimen.

Visceral leishmaniasis emerging as an important opportunistic infection in HIV-infected persons living in areas nonendemic for Leishmania donovani

BACKGROUND

Visceral leishmaniasis is an important infection in patients infected with human immunodeficiency virus and living in areas endemic for Leishmania sp. Leishmaniasis, however, is rarely suspected in patients residing in nonendemic countries.

METHODS

Retrospective case analysis of 15 patients with human immunodeficiency virus infection and leishmaniasis treated at seven German clinics. The clinicopathological features and the diagnostic role of biopsy and/or cytology as compared to serology were evaluated.

RESULTS

All patients were severely immunocompromised. One patient was first diagnosed at autopsy. One patient with mucocutaneous disease was diagnosed by nasal biopsy. All others had amastigotes detected in bone marrow (13/13), liver (3/3), and gastrointestinal mucosa (4/4). Serology was positive in only 6 or 13.

CONCLUSION

Visceral leishmaniasis is an important opportunistic infection in patients with acquired immunodeficiency syndrome and it must be ruled out in every patient with fever and/or pancytopenia and an appropriate travel history. Because serological diagnosis is often insufficient, pathologists must be aware of the association between human immunodeficiency virus infection and leishmaniasis. Diagnosis depends on detection of the parasite in submitted specimens.

A dose comparison study of didanosine in patients with very advanced HIV infection who are intolerant to or clinically deteriorate on zidovudine. German ddI Trial Group

OBJECTIVE

Zidovudine (ZDV) is the only antiretroviral drug which has been shown to reduce mortality in patients with symptomatic HIV disease, but its use is restricted by intolerance in a significant proportion of patients. Additionally, the efficacy of ZDV therapy appears to decrease after prolonged treatment particularly in the advanced stage of HIV disease. Therefore, alternative antiretroviral regimens for patients are needed. In this study, didanosine (ddI; 2',3'-dideoxyinosine), another HIV reverse transcriptase inhibitor, was evaluated.

DESIGN

A total of 426 patients with AIDS or AIDS-related complex (ARC) who were intolerant to or clinically progressing on ZDV therapy and who had CD4+ cell counts < or = 150 x 10(6)/l were randomized to receive either a high (750 mg for bodyweight > or = 60 kg or 500 mg for bodyweight < 60 kg) or a low (200 mg and 134 mg, respectively) dose of ddI daily.

SETTING

The patients were recruited from 31 German and Austrian AIDS clinical primary-care centres.

RESULTS

The study was stopped after the second interim analysis due to a statistically significant difference in the incidence of pancreatitis (nine versus 26; relative risk, 2.92; P = 0.003) and neuropathy (28 versus 43; relative risk, 1.55; P = 0.05) in favour of the low dose. There was no difference between the low and high dosage groups in survival rate at 6 (80 versus 80%) and 12 months (61 versus 65%), number of deaths [82 (43.6 per 100 patient-years) versus 84 (44.4 per 100 patient-years)], progression from ARC to AIDS or to AIDS or death, or average number of new/recurrent opportunistic infections (2.8 versus 3.0 per patient).

CONCLUSIONS

This study cannot conclude on ddI efficacy but it shows that in patients with advanced HIV disease for whom no alternative antiretroviral therapy is available and ddI therapy is considered, daily doses < 750 mg should be administered.

[Pulmonary mucormycosis in an HIV-infected patient]

A 51-year-old man, known to have chronic-aggressive hepatitis B, HIV infection and exertional dyspnoea, was hospitalized because of acute physical deterioration, cough with whitish exudate and dyspnoea at rest. Despite a CD4/CD8 ratio of 0.16 no prophylactic measures against Pneumocystis carinii had been taken. On examination the lungs were unremarkable, but the liver was enlarged and there were petechiae over all parts of the body. Laboratory tests showed impaired liver functions and a rise in lactate dehydrogenase activity (538 U/l). Chest radiogram demonstrated small to very small infiltrates in the lung. As Pneumocystis carinii pneumonia was suspected but bronchoscopy was too risky, he was at first treated with trimethoprim/sulphamethoxazole (four times 320/1600 mg/24 h intravenously). When this failed, he received pentamidine (4 mg/kg, after 4 days 2 mg/kg intravenously), and finally cefotiam (twice 2 g daily), tobramycin (three times 40 mg daily) and corticoids (100 mg). Despite this treatment he died after 10 days from respiratory failure. Autopsy revealed interstitial pneumonia throughout the lung as well as focal mucor infiltrations in the wall of middle-calibre lung veins. Mucor is a ubiquitous, facultatively pathogenic mold fungus.

Foscarnet and ganciclovir combination therapy for CMV disease in HIV-infected patients

An open prospective trial of combined ganciclovir and foscarnet therapy for 3 weeks was initiated in 14 episodes of severe CMV-disease in 13 HIV-infected patients (all CDC class IV, age 30-42, median 34 years, CD4+ cell count 0-80, median 10/microliters). In seven episodes of gastrointestinal disease (five colitis, two esophagitis) remission of symptoms and mucosal changes was achieved in five. In seven episodes of retinitis, scarring was achieved in six. Renal toxicity was seen in two patients, moderate hematologic toxicity in eight patients. Overall efficacy was comparable to monotherapy; no new toxicities were seen with the combination of these two drugs.

[Primary and secondary prevention of Pneumocystis carinii pneumonia with pentamidine aerosol. Effectiveness, side effects and incidence of extrapulmonary Pneumocystis carinii manifestations]

BACKGROUND

We report on a retrospective study in 544 HIV-positive patients, (42 women, 502 men, mean age 35 years) showing CD4 lymphocyte counts below 200 c/mcl or after their cure of Pneumocystis carinii pneumonia, who received 300 mg pentamidine aerosol as prophylaxis against Pneumocystis carinii pneumonia every four week.

PATIENTS AND METHODS

277 patients were asymptomatic, 120 in the AIDS related complex stage (ARC) and 147 in the full stage of AIDS. The mean follow-up was 14.4 months.

RESULTS

A total of 25 cases of Pneumocystis carinii pneumonia was observed (3.83/year): in the primary prophylaxis group 18 (3.25%/year), in the secondary prophylaxis group seven (6.8%/year). By introducing the loading dose (one inhalation per day for five consecutive days for patients with CD4 cell counts below 150 c/mcl) we reduced the percentage of early manifestations within the first three months from 61% to 14%. No extrapulmonary Pneumocystis carinii manifestation was observed.

CONCLUSION

This study supports the efficacy of pentamidine aerosol prophylaxis of primary and secondary Pneumocystis carinii pneumonia.

Fluconazole therapy of oral candidiasis in HIV-infected patients: results of a multicentre study

In an open phase-III study 103 HIV-positive patients with oral candidiasis were treated with oral fluconazole 100 mg/day for 7-21 days (mean 12.2 +/- 6.1 days). Ninety per cent of the patients presented with the full clinical picture of AIDS, in 83% CD4-lymphocytes were < 100/mm3. Clinical and mycological (smear and mouth rinsing) examinations were performed at the start of therapy, after weeks 1, 2, and 3, and at the end of therapy. The clinical findings showed fluconazole therapy to have achieved cure in 71% of the patients and improvement in 16%. Therapy failed in 13%. Mycological tests revealed elimination in 57% and reduction in colony counts in 23% of patients. Therapy failure according to mycological criteria was observed in 20% of all subjects. Adverse events were recorded for 26% of all patients. A causal connection with study therapy was considered as "unlikely" in 20 cases, "questionable" in 17 cases, and "likely" in three cases. Premature discontinuation of fluconazole therapy was required in seven patients, in three of them because of adverse events due to fluconazole. Even in patients with advanced HIV infection and consequently severe immunodeficiency, fluconazole is an important improvement of the therapeutic spectrum.

Antiviral and immunological effects of escalating low doses of zidovudine in HIV-positive patients

Twenty-eight patients with different stages of HIV infection who had not undergone antiretroviral pretreatment were treated with an escalating dose regimen of zidovudine (4 weeks 2 x 50 mg, 4 weeks 2 x 100 mg, 4 weeks 2 x 250 mg). CD4+ cell counts and p24 antigen levels were monitored every four weeks. Twenty-one patients were evaluable. p24 antigen levels showed a significant decrease after four weeks (p < 0.01, Sign test, Wilcoxon matched pairs test) that was sustained until week 12 without a further significant decrease. CD4+ cell counts increased significantly within the first four weeks (p < 0.01, Sign test, Wilcoxon matched pairs test). This increase was sustained until week 12 but no further significant increase was noted. Mean corpuscular erythrocyte volume values increased significantly after week 4 and continued to rise until week 12. These results demonstrate antiretroviral activity of a very low zidovudine dose, however low doses should not be used for treatment unless the clinical efficacy is shown to be equivalent to that of standard doses.

[Secondary prevention of cytomegalovirus retinitis with ganciclovir]

The prophylaxis of cytomegalovirus retinitis reactivation is effective in reducing the risk of blindness and in prolonging the remission interval and time of survival if given daily throughout life. In this study, a newly developed therapeutic regimen with 3 infusions a week was compared to the conventional maintenance therapy of 5 infusions a week using the same total weekly dose. For this purpose, ten patients were given 10 mg ganciclovir/kg 3 times a week (group A), and 18 received 6 mg ganciclovir/kg once daily for 5 days a week (group B). Only patients with newly diagnosed retinitis were included in this study. Both groups were comparable regarding their general health and ocular state at the beginning of the study. Induction therapy for stabilization of retinitis had to be given for 17.1 and 16.7 days (P = 0.785). Visual acuity was 0.5 and 0.7, respectively, at the beginning (P = 0.128) and 0.5 each at the end of the study (P = 0.875). Fifty-six percent of both groups presented with central retinal involvement at the beginning, whereas it was 56 and 78%, respectively, at the end (P = 0.250). The retinitis was found to have progressed more than 0.5 papilla diameters (pd) after 63.8 and 64.0 days (P = 0.996) and more than 1 pd after 117.6 and 77.8 days (P = 0.350). New induction therapy had to be performed after 147.9 and 131.5 days, respectively (P = 0.598). The maintenance therapy had to be interrupted due to side effects for 1.4 and 8.3 days, respectively (P = 0.185). According to these results, the prophylaxis of retinitis reactivation with 3 x 10 mg ganciclovir/kg per week is as effective as the established one with 5 x 6 mg/kg per week and can thus be recommended for an improvement in the quality of life for the patients concerned. No problems with this therapy were noted.

A preparation from bovine colostrum in the treatment of HIV-positive patients with chronic diarrhea

In a prospective, open, uncontrolled study 25 patients infected with the human immunodeficiency virus with chronic refractory diarrhea and either confirmed cryptosporidiosis (n = 7) or absence of demonstrable pathogenic organisms (n = 18) were treated with a daily oral dose of 10 g of an immunoglobulin preparation from bovine colostrum over a period of 10 days. Among the 7 patients with cryptosporidiosis, this treatment led to complete remission in 3 and partial remission in 2. Among the 18 patients with diarrhea and negative stool culture, complete remission of diarrhea was obtained in 7 and partial remission in 4. In the remaining 2 patients with cryptosporidiosis and the 7 patients with diarrhea but no demonstrable pathogens treatment produced no significant improvement of the diarrhea. Subsequent doubling of the Lactobin dose (2 x 10 g daily) in 8 of the nonresponders led to complete remission in one case and at least partial remission in a further 4 patients. Treatment of refractory diarrhea with 10 g immunoglobulins from bovine colostrum per day constitutes an important therapeutic approach and led to complete (40%) or partial (24%) remission of diarrhea in 64% of the patients described here.

[Effect of alfa-2b interferon on prognostic parameters and clinical events in HIV positive patients in the LAS/ARC stage]

A number of in vivo and in vitro results suggest that interferons have an antiretroviral effect on HIV. To check this, 15 HIV-positive patients who had no full-blown AIDS, were treated with recombinant interferon alpha 2b (5 mill. IU s. c. three times a week) over a period of six months. Twelve to 16 weeks after the initiation of treatment, an increase in CD 4 lymphocytes (+16%), NK cells (+16%), lymphocytes stimulation by con A (+ 176%), neopterin (+66%), and beta-2-microglobulin (+19%) was observed. By the end of the study, all these parameters had slightly decreased again. In all patients with CD4 lymphocytes greater than 0.2 c/nl, we observed a decrease in p24 antigen levels, but in patients with CD4 lymphocytes less than 0.2 c/nl, an increase. It would thus seem that any antiretroviral effect of IFN (as shown by the p24 antigen parameter) is more pronounced in patients with superior immune parameters.

[Clinical and serological findings of syphilis in HIV-infected patients]

To identify the characteristic features of lues in patients infected with HIV, 402 HIV-positive patients were examined for serological and clinical signs of lues. 141 patients (133 male, 8 female, mean age 36 [18-69] years) had a positive lues serology. Treatment for lues was required in 20 of the 141 cases (14%). In ten patients (one case of lues I, nine cases of lues II) dermatological signs were predominant, macular exanthemas (n = 4) and palmo-plantar syphilides (n = 3) being most frequent. Three patients had seropositive latent lues. Eight patients presented with signs of an active neurolues (lues II: n = 1; lues III: n = 6; lues IV: n = 1). In three of the eight cases the serum FTA-ABS-IgM findings were negative. In these three patients the need for a specific treatment was realized only on the basis of cerebrospinal fluid (CSF) examination in conjunction with the clinical findings and the anamnesis. This result makes it very clear that indication for CSF puncture should be more liberal in some HIV infected patients. The markedly high proportion of cases of neurolues (40% of the luetic patients requiring treatment) is possibly due to reactivation of old lues infections.