Trends over calendar time in antiretroviral treatment success and failure in HIV clinic populations

OBJECTIVE

Effective antiretroviral therapy (ART) has transformed the care of people with HIV, but it is important to monitor time trends in indicators of treatment success and antic future changes.

METHODS

We assessed time trends from 2000 to 2007 in several indicators of treatment success in the UK Collaborative HIV Cohort (CHIC) Study, and using national HIV data from the Health Protection Agency (HPA) we developed a model to project future trends.

RESULTS

The proportion of patients on ART with a viral load <50 HIV-1 RNA copies/mL increased from 62% in 2000 to 84% in 2007, and the proportion of all patients with a CD4 count <200 cells/microL decreased from 21% to 10%. During this period, the number of patients who experienced extensive triple class failure (ETCF) rose from 147 (0.9%) to 1771 (3.9%). The number who experienced such ETCF and had a current viral load >50 copies/mL rose fromz 118 (0.7%) to 857 (1.9%). Projections to 2012 suggest sustained high levels of success, with a continued increase in the number of patients who have failed multiple drugs but a relatively stable number of such patients experiencing viral loads >50 copies/mL. Numbers of deaths are projected to remain low.

CONCLUSIONS

There have been continued improvements in key indicators of success in patients with HIV from 2000 to 2007. Although the number of patients who have ETCF is projected to rise in the future, the number of such patients with viral loads >50 copies/mL is not projected to increase up to 2012. New drugs may be needed in future to sustain these positive trends.

Discordant responses on starting highly active antiretroviral therapy: suboptimal CD4 increases despite early viral suppression in the UK Collaborative HIV Cohort (UK CHIC) Study

OBJECTIVES

Patients starting highly active antiretroviral therapy (HAART) may have a suboptimal CD4 increase despite rapid virological suppression. The frequency and the significance for patient care of this discordant response are uncertain. This study was designed to determine the incidence of a discordant response at two time-points, soon after 6 months and at 12 months, and to determine the relationship with clinical outcomes.

METHODS

Data obtained in the UK Collaborative HIV Cohort Study were analysed. A total of 2584 treatment-naïve patients starting HAART with HIV viral load (VL) > 1000 HIV-1 RNA copies/mL at baseline and < 50 copies/mL within 6 months were included in the analysis. Patients were classified at either 6-10 (midpoint 8) months or 10-14 (midpoint 12) months as having a discordant (CD4 count increase < 100 cells/microL from baseline) or concordant response (CD4 count increase >or= 100 cells/microL).

RESULTS

Discordant responses occurred in 32.1% of patients at 8 months and in 24.2% at 12 months; 35% of those discordant at 8 months were concordant at 12 months. A discordant response was associated with older age, lower baseline VL, and (at 12 months) higher baseline CD4 cell count. In a multivariate analysis it was associated with an increased risk of death, more strongly at 12 months [incidence rate ratio (IRR) 3.35, 95% confidence interval (CI) 1.73-6.47, P < 0.001] than at 8 months (IRR 2.08, 95% CI 1.19-3.64, P = 0.010), but not with new AIDS events.

CONCLUSIONS

Discordant responders have a worse outcome, but assessment at 12 months may be preferred, given the number of 'slow' responders. Management strategies to improve outcomes for discordant responders need to be investigated.

The associations between age and the development of laboratory abnormalities and treatment discontinuation for reasons other than virological failure in the first year of highly active antiretroviral therapy

OBJECTIVE

The aim of this study was to describe the relationship between age and the time to treatment discontinuation in the absence of virological failure as well as the development of specific laboratory abnormalities, in patients starting highly active antiretroviral therapy (HAART) for the first time.

METHODS

Analyses included 8708 antiretroviral-naïve patients from the UK Collaborative HIV Cohort (CHIC) study who started HAART from 1998 onwards. We considered time to the first discontinuation of any drug in the initial HAART regimen for reasons other than virological failure; the association between this and age at the start of HAART was determined using proportional hazards regression after adjustment for potential confounders. The incidence of specific laboratory abnormalities in the first year after starting HAART was compared in those of different ages using multiple logistic regression.

RESULTS

A total of 2650 patients discontinued at least one drug in their HAART regimen in the first year for reasons other than virological failure; after controlling for confounders, those aged < 30 years at the time of starting HAART were more likely to discontinue than those aged 30-39 years [relative hazard (RH) 1.12; 95% confidence interval (CI) 1.01, 1.24] as were those aged > or = 50 years (RH 1.14; 95% CI 1.00, 1.31). There were strong associations between greater age and raised total cholesterol, decreased haemoglobin and raised triglycerides over the first year, although the latter disappeared after adjustment for pre-HAART levels, suggesting that this finding reflected higher pre-HAART triglyceride levels in older individuals.

CONCLUSIONS

Continued attempts to improve the tolerability of HAART regimens may help to sustain the good outcomes in all age groups over the longer term.

Patterns and predictors of the use of different antiretroviral drug regimens at treatment initiation in the UK

BACKGROUND

We describe the patterns of antiretroviral drug use at treatment initiation from 1996 to 2005 in a large UK multicentre cohort.

METHODS

We examined trends over time and across 10 clinical sites in stage of disease and type of antiretroviral therapy (ART). Multivariable regression was used to identify factors associated with the CD4 cell count at ART initiation, and with the choice of a protease inhibitor (PI) over a nonnucleoside reverse transcriptase inhibitor (NNRTI), and use of nevirapine over efavirenz.

RESULTS

A total of 14 252 patients initiated ART, of whom 54% had a CD4 count <200 cells/microL. The most important predictors of starting ART at a lower CD4 cell count were being male, nonwhite, and heterosexual or an injecting drug user (P<0.0001). Among those starting ART, the use of highly active ART increased from 23% in 1996 to >96% from 2000 onwards. There were differences over time and across the clinics in the use of PIs vs. NNRTIs, in the choice of specific PIs, NNRTIs and nucleoside reverse transcriptase inhibitor (NRTI) backbone, and in the rate at which prescribing practices changed.

CONCLUSIONS

Clinic site and calendar year were important determinants of choice of drug at ART initiation, whereas clinical and demographic characteristics were more important in influencing the CD4 cell count at initiation of ART.

CD4 cell count and initiation of antiretroviral therapy: trends in seven UK centres, 1997-2003

OBJECTIVES

We examined whether the timing of initiation of antiretroviral therapy (ART) in routine clinical practice reflected treatment guidelines, which have evolved towards recommending starting therapy at lower CD4 cell counts.

METHODS

We analysed longitudinal data on 10,820 patients enrolled in the UK Collaborative HIV Cohort (UK CHIC) Study, which includes seven large clinical centres in south-east England. CD4 cell and viral load measurements performed in the period between 1 January 1997 and 31 December 2003 were classified according to whether ART was subsequently initiated or deferred, to estimate the probability of ART initiation by CD4 count and viral load over time. The effect of nonclinical factors (age, sex, ethnicity, and exposure category) was analysed by logistic regression. Kaplan-Meier analysis was used to estimate the proportion of patients who had initiated ART by a particular CD4 count among 'early' presenters (initial CD4 cell count >500 cells/microL).

RESULTS

There was a tendency to initiate ART at lower CD4 cell counts over time in the years 1997-2000, especially in the range 200-500 cells/microL, with little change thereafter. An estimated 34% of HIV-infected individuals having presented early initiated ART at a CD4 count <200 cells/microL. We also found an independent influence of viral load, which was particularly pronounced for CD4 <350 cells/microL. Use of injection drugs was the only nonclinical factor associated with initiation of ART at lower CD4 cell counts.

CONCLUSIONS

The initiation of ART in the clinics included in this analysis reflected evolving treatment guidelines. However, an unexpectedly high proportion of patients started ART at lower CD4 counts than recommended, which is only partly explained by late presentation.

The relationship between the zinc nutritive status and biochemical markers of bone turnover in older European adults: the ZENITH study

OBJECTIVE

To investigate the relationship between indices of zinc nutritive status and biochemical markers of bone turnover in older adult European subjects.

DESIGN

Use of baseline data from a multicentre prospective zinc intervention (ZENITH) study.

SETTING

Centres in France, Italy and Northern Ireland.

PARTICIPANTS

A total of 387 healthy adults, aged 55-87 y.

METHODS

Zinc intake was assessed by 4-day recall records. Circulating and urinary biochemical zinc status measures were assessed by atomic absorption spectrophometry. Serum bone-specific alkaline phosphatase and osteocalcin were assessed by ELISA and urinary pyridinoline (Pyr) and deoxypyridinoline (Dpyr) by HPLC.

RESULTS

Zinc intake was negatively correlated with urinary Pyr and Dpyr (r = -0.298 and -0.304, respectively; P < 0.0001), but was not correlated with bone formation markers. There was a tendency for serum zinc to be negatively correlated with urinary Dpyr (r = -0.211; P = 0.080). Erythrocyte zinc was negatively correlated with serum osteocalcin (r = -0.090; P < 0.0001). None of the other correlations were significant. After adjustment for confounder (age, gender and research centre) the only significant association that remained was between serum osteocalcin and erythrocyte zinc (beta = -0.124; P = 0.011).

CONCLUSIONS

There was some, albeit inconsistent, evidence of a relationship between zinc nutritive status and bone turnover in the older adult participants of the ZENITH study.

Antileukemic effect of daclizumab in CD25 high-expressing leukemias and impact of tumor burden on antibody dosing

Humanized anti-CD25 antibody, daclizumab, was applied in a pilot study of 10 patients with CD25(+) leukemias and pharmacokinetic/pharmacodynamic properties were characterized. Two widely held concepts - tumor sink accelerating pharmacokinetics and higher antigen expression correlating with target cell clearance - were supported by this first systematic evaluation of these questions with actual human clinical data. A flexi-dosing regimen was validated for maintaining target drug levels in vivo with a wide range of tumor burdens. Daclizumab induced clearance of peripheral leukemic cells when highly positive for CD25, but durable responses were not obtained. If daclizumab will have a role in antileukemic therapy, it may be in minimal disease settings or as a component of a combination regimen, but only when CD25 expression is high.

Reorganization of small Co particles on Al2O3 surfaces monitored by ferromagnetic resonance

Changes of the magnetic properties of ferromagnetic Co particles deposited on the radical31 x radical31R +/- 9 degrees reconstructed alpha-Al2O3(0001) as well as on a thin alumina film grown on a NiAl(110) substrate were investigated as a function of thermal annealing. On the thin film changes of the magnetic response were found above 500 K which correlates with changes in the particle size distribution. Annealing to 870 K leads to a permeation of the metal though the oxide film which causes significant changes in the ferromagnetic resonance response. On the alpha-Al2O3 single crystal sintering of particles requires temperatures above 600 K being about 100 K higher as compared to the thin alumina film. For large clusters intraparticle redistribution takes place already below 600 K a phenomenon not observed for the small clusters. In addition, a significant dependence of the measured g values from the substrate as well as the thermal treatment is found which can be understood in terms of the structural properties of the systems.

Intracellular T lymphocyte cytokine profiles in the aqueous humour of patients with uveitis and correlation with clinical phenotype

This study aimed to investigate whether T cells in aqueous humour are different in different types of uveitis and correlate with clinical phenotype. Patients with clinically different types of uveitis, but all displaying active anterior uveitis, were phenotyped and samples of aqueous humour (AH) and peripheral blood (PB) collected. Cells from AH and PB were separated by centrifugation and by density gradient centrifugation (to obtain mononuclear cells PBMC), respectively. Cells were activated with PMA and ionomycin in the presence of Brefeldin A, stained for surface markers and intracellular cytokines, and analysed by flow cytometry. The cytokine profile was correlated with the clinical phenotype. Increased percentages of interleukin (IL)-10+-, but not interferon (IFN)-gamma+ T lymphocytes were found in AH compared with PB in patients with acute anterior uveitis (AAU), FHC or chronic panuveitis (PU). There was a trend towards elevated levels of IL-10+ T cells in AH from patients with FHC compared with AH from acute uveitis and panuveitis patients. Increased levels of IL-10+ T cells in AH compared with PB were also found in samples from patients with isolated uveitis, but not those with associated systemic disease. Levels of cytokine-positive T cells were not associated with the use of topical steroids or to the severity of the anterior uveitis. While type I cytokine-producing T lymphocytes are present in AH during AU, the presence of increased proportions of IL-10+ T lymphocytes in AH from patients with uveitis may be indicative of an anti-inflammatory mechanism that may influence the type and course of ocular inflammation in these patients.

Morphological differences between Saturn's ultraviolet aurorae and those of Earth and Jupiter

It has often been stated that Saturn's magnetosphere and aurorae are intermediate between those of Earth, where the dominant processes are solar wind driven, and those of Jupiter, where processes are driven by a large source of internal plasma. But this view is based on information about Saturn that is far inferior to what is now available. Here we report ultraviolet images of Saturn, which, when combined with simultaneous Cassini measurements of the solar wind and Saturn kilometric radio emission, demonstrate that its aurorae differ morphologically from those of both Earth and Jupiter. Saturn's auroral emissions vary slowly; some features appear in partial corotation whereas others are fixed to the solar wind direction; the auroral oval shifts quickly in latitude; and the aurora is often not centred on the magnetic pole nor closed on itself. In response to a large increase in solar wind dynamic pressure Saturn's aurora brightened dramatically, the brightest auroral emissions moved to higher latitudes, and the dawn side polar regions were filled with intense emissions. The brightening is reminiscent of terrestrial aurorae, but the other two variations are not. Rather than being intermediate between the Earth and Jupiter, Saturn's auroral emissions behave fundamentally differently from those at the other planets.

Vitamin D intake and status in Irish postmenopausal women

OBJECTIVE

The objective of this study was to assess vitamin D status during late-summer and late-winter/early-spring in postmenopausal Irish women, and whether it was influenced by vitamin D-containing supplement use.

DESIGN

A longitudinal observational study.

SETTING

Cork City, Ireland (51 degrees north).

SUBJECTS

A total of 59 apparently healthy, free-living, postmenopausal women aged between 51 and 69 y were sampled during February/March 2002. Of these, 48 and 47 returned during August/September 2002 and February/March 2003, respectively. None of the women were suffering from any medical condition likely to affect vitamin D status. Fasting serums were collected and analysed for 25-hydroxyvitamin D (25 (OH) D) and parathyroid hormone (PTH) by enzyme immunoassays.

RESULTS

Mean daily intake of vitamin D was 3.2 microg from food sources alone and 5.8 microg when vitamin D-containing supplements were included (P<0.01). Serum 25 (OH) D was significantly lower (P<0.001) during February/March 2002 than both August/September 2002 and February/March 2003. Serum 25 (OH) D was also significantly higher (P < or = 0.05) in women who were vitamin D-containing supplement users than nonusers during all three sampling points. Between 17 and 36% of women had inadequate vitamin D status (defined as serum 25 (OH) D <40 nmol/l) during late-winter, but only 4% had inadequate vitamin D status during late-summer. Serum 25 (OH) D was inversely related to serum PTH (r = -0.33; P = 0.028).

CONCLUSION

Suboptimal vitamin D status is common in postmenopausal Irish women during winter. Vitamin D supplementation is associated with improved vitamin D status, even during summertime.

A comparison of the sports safety policies and practices of community sports clubs during training and competition in northern Sydney, Australia

OBJECTIVES

To compare the safety policies and practices reported to be adopted during training and competition by community sports clubs in northern Sydney, Australia.

METHODS

This cross sectional study involved face to face interviews, using an 81 item extensively validated questionnaire, with representatives of 163 community netball, rugby league, rugby union, and soccer clubs (response rate 85%). The study was undertaken during the winter sports season of 2000. Two separate 14 item scales were developed to analyse the level of safety policy adoption and safety practice implementation during training and competition. The statistical analysis comprised descriptive and inferential analysis stratified by sport.

RESULTS

The reliability of the scales was good: Cronbach's alpha = 0.70 (competition scale) to 0.81 (training scale). Significant differences were found between the safety scores for training and competition for all clubs (mean difference 11.2; 95% confidence interval (CI) 10.0 to 12.5) and for each of the four sports: netball (mean difference 14.9; 95% CI 12.6 to 17.2); rugby league (mean difference 10.3; 95% CI 7.1 to 13.6); rugby union (mean difference 9.4; 95% CI 7.1 to 11.7); and soccer (mean difference 8.4; 95% CI 6.5 to 10.3).

CONCLUSIONS

The differences in the mean competition and training safety scores were significant for all sports. This indicates that safety policies were less often adopted and practices less often implemented during training than during competition. As injuries do occur at training, and sports participants often spend considerably more time training than competing, sporting bodies should consider whether the safety policies and practices adopted and implemented at training are adequate.

The development of a tool to audit the safety policies and practices of community sports clubs

Despite increased national effort directed at sports injury prevention in Australia since the mid 1990s, there is a lack of information available about the sports safety policies and practices of community sports clubs. The aim of this study was to develop a valid and reliable sports safety audit tool (SSAT) to identify these safety policies and practices. A literature review identified issues to be covered by the SSAT. Consultation with "experts" and piloting the SSAT with 19 community sports clubs in metropolitan Sydney established face and content validity. Test-retest reliability was assessed in six clubs. Inter-rater reliability was assessed using twenty-four independent representatives from eight clubs. Face and content validity studies identified issues to include in the SSAT and improvements to language and layout. Test-retest reliability was 91% (range 68-100%). Inter-rater reliability ranged from 40-65% when missing data and 'don't know' answers were included, and from 62-75% when only 'definitive' answers were included. Club presidents and secretaries provided more definitive information than other informants. A preliminary list of safety issues that clubs addressed well or poorly was identified. The SSAT is a useful tool for gathering baseline data, benchmarking and targeting sports safety interventions with community sports clubs. Club presidents and secretaries are the preferred contact point and a face-to-face interview is the best administration mode. A tool to identify safety policies and practices is now available for use by anyone supporting community sports clubs to improve safety.

Emergency and primary care at a Melbourne hospital: reasons for attendance and satisfaction

The reasons for attendance, presenting health problems, functional status, pain and severity, and satisfaction with emergency and primary care were examined using routinely collected data and an interviewer-assisted survey of patients. Patients attended, mostly after hours, because they believed their health problems required hospital-based management. GPs referred for admission and further evaluation. Ethnicity, employment status, gender and age contributed to differences in access, morbidity and pain scores. Pain scores, functional status and English language skills influenced satisfaction. Culturally sensitive hospital- and community-based clinicians are important to promote better services, after-hours care, referral and triage. It is essential to have appropriate policy and legislation, adequate infrastructure and resources, good communication strategies, telecommunication technology, explicit evidence-based protocols for shared care, referral and triage and ongoing training and support for clinicians and consumers.

Tracking the spread of a lacZ-tagged herpes simplex virus type 1 between the eye and the nervous system of the mouse: comparison of primary and recurrent infection

The spread of herpes simplex virus type 1 (HSV-1) during primary ocular infection and after reactivation of latent infection in the trigeminal ganglion (TG) was examined in the mouse using a genetically modified virus containing the lacZ reporter gene under the control of the immediate-early 110 promoter. Whole tissue mounts of the eye and lids, their sensory nerves, and TG with the attached dorsal root entry zone (DRE) into the central nervous system (CNS) were stained for beta-galactosidase. Sixteen hours after inoculation of the cornea by scarification, staining was found in the scarified epithelium of the cornea and in the unscarified conjunctiva. By 24 h, staining was also seen in a few TG neurons and by 96 h their number had greatly increased and their distribution was more widespread. Stained cells (identified as Schwann cells by their staining for glial fibrillary acidic protein [GFAP] or S-100) in the TG were first seen close to stained neurons at 40 h, and by 48 h lines of such cells extended partway toward the periphery and toward the DRE. By 72 h, these lines had reached the periphery and the DRE where the adjacent CNS was also stained. In the cornea, stained cells with the morphology and arrangement of Schwann cells were seen from 40 to 120 h. After reactivation of latent infection, 10 of 22 samples had positively stained neurons. In eight samples, corneal and lid epithelial cells were stained. No stained Schwann cells were seen in the TG; however, branched networks of such cells were present in the cornea and the lids. This detailed sequential analysis has provided new information on the involvement of Schwann cells in the pathogenesis of primary and recurrent HSV-1 disease in the TG and the cornea.

Secreted euryarchaeal microhalocins kill hyperthermophilic crenarchaea

Few antibiotics targeting members of the archaeal domain are currently available for genetic studies. Since bacterial antibiotics are frequently directed against competing and related organisms, archaea by analogy might produce effective antiarchaeal antibiotics. Peptide antibiotic (halocin) preparations from euryarchaeal halophilic strains S8a, GN101, and TuA4 were found to be toxic for members of the hyperthermophilic crenarchaeal genus Sulfolobus. No toxicity was evident against representative bacteria or eukarya. Halocin S8 (strain S8a) and halocin R1 (strain GN101) preparations were cytostatic, while halocin A4 (strain TuA4) preparations were cytocidal. Subsequent studies focused on the use of halocin A4 preparations and Sulfolobus solfataricus. Strain TuA4 cell lysates were not toxic for S. solfataricus, and protease (but not nuclease) treatment of the halocin A4 preparation inactivated toxicity, indicating that the A4 toxic factor must be a secreted protein. Potassium chloride supplementation of the Sulfolobus assay medium potentiated toxicity, implicating use of a salt-dependent mechanism. The utility of halocin A4 preparations for genetic manipulation of S. solfataricus was assessed through the isolation of UV-induced resistant mutants. The mutants exhibited stable phenotypes and were placed into distinct classes based on their levels of resistance.