Determinants of adherence to highly active antiretroviral therapy (HAART) in Chinese HIV/AIDS patients

OBJECTIVE

Drug adherence is crucial to the success of highly active antiretroviral therapy (HAART) in the treatment of HIV disease. Adherence to HAART and its determinants may, however, differ across HIV/AIDS populations.

METHODS

We retrospectively studied drug adherence by self-report in HIV-1 infected Chinese patients who have been on HAART for at least 1 year as at the end of year 2000. HAART is defined as three or more antiretrovirals with at least one protease inhibitor or non-nucleoside analogue reverse transcriptase inhibitor.

RESULTS

The last drug adherence level assessed by self-report in 161 Chinese patients were: grade A (100%) - 130, 80.7%; grade B (95-99%) - 25, 15.5%; grade C (90-94%) - three, 1.9% and grade D (< 90%) - three, 1.9%. Patients with full adherence were more likely to have undetectable (< 500 copies/mL) plasma virus level (adjusted OR, 4.22; 95% CI, 1.75-12.33). Patients' demographics, HIV disease status and antiretroviral regimen did not affect adherence. Partial drug adherence was, however, independently associated with the psychosocial factors of missing clinic appointments (adjusted OR, 3.13; 95% CI, 1.23-8.33), forgetfulness (adjusted OR, 4.55; 95% CI, 1.64-12.5) and a busy work life (adjusted OR, 6.67; 95% CI, 1.75-25).

CONCLUSION

There were similarities and differences in determinants affecting HAART adherence in Chinese compared with other patients. Psychosocial factors rather than HIV disease or treatment were more important factors in our Chinese patients. The relevance of patient populations and care setting for adherence to HAART shall be further studied.

Lack of ageing cohort effect among sexually acquired HIV infections in Hong Kong

We studied HIV rate in different age populations and whether there has been on-going new infections in Hong Kong, by examining the age characteristics and their temporal trend of reported HIV infections. It was found that people in the age group 25-34 were worst hit by the local epidemic. Ageing cohort effect was not apparent for the age pattern of sexually-acquired infections reported from 1987 to 2000, with the annual median ages ranged from 31.5 to 36 years (regression coefficient 0.14, 95% confidence interval -0.14 to 0.42, P = 0.295). Similar temporal age patterns were observed for individual subgroups of homo-/bisexuals, heterosexuals and female heterosexuals. The findings suggested the occurrence of new HIV infections over the years in Hong Kong, despite maintenance of a low prevalence. Albeit capturing largely prevalent infections, reported HIV/AIDS data could be tapped for understanding the evolving epidemic pattern to better evaluate and target current prevention programmes.

The implication of a reduced-dose hepatitis B vaccination schedule in low risk newborns

Five hundred and seventy-four babies born to HBsAg negative mothers in Hong Kong received either a regular (5 micro g) or reduced (2.5 micro g) three-dose regimen of recombinant hepatitis B vaccine. A significantly higher anti-HBs positivity rate (>or=10 mIU/ml), geometric mean titer (GMT) and the maintenance of a high anti-HBs level (>or=100 mIU/ml) were observed with the regular-dose regimen. The differences persisted, however, only up to 1 year post-vaccination. Over an 8-year period, only 1% of the vaccinees demonstrated anti-HBc seroconversion and none had become HBsAg positive. The long-term efficacy of the reduced-dose regimen was confirmed, even in an HBV endemic population.

Microtexture characterization of PZT ceramics and thin films by electron microscopy

Crystallographic orientations of lead zirconate titanate, Pb(Zr(x),Ti(1-x))O(3) abbreviated PZT, were investigated by the technique of electron backscatter diffraction pattern (EBSP) in the scanning electron microscope (SEM). The samples included unpoled and poled ceramics and a thin film. Several hundreds of crystal orientations in the bulk ceramics and thin films were examined by EBSP and the results were plotted in microtexture pole- and inverse pole-figures for determination of the average and local preferred orientations. In addition, local textures in certain selected regions in PZT ceramics and the misorientations between the nearest neighboring grains were also determined.

Epidemiology and detection of human immunodeficiency virus among pregnant women in Hong Kong

OBJECTIVES

To determine the epidemiology of human immunodeficiency virus infection among pregnant women and the neonatal outcomes in Hong Kong.

DESIGN

Retrospective observational study composed of two parts: record review of pregnant women and unlinked anonymous screening of cord blood from neonates.

SETTING

Two human immunodeficiency virus clinics and the Government Virus Unit.

PARTICIPANTS

Female patients attending the two clinics who became pregnant and neonates who underwent routine metabolic screening by the Government Virus Unit between 1992 and 1999.

MAIN OUTCOME MEASURES

The outcomes of neonates born to women who had human immunodeficiency virus infection during pregnancy.

RESULTS

Forty-one human immunodeficiency virus-related pregnancies were recorded among 32 infected women. Fifteen pregnancies were terminated, of which 14 were in women who knew their infection status before conception. Twenty-six pregnancies continued to term, resulting in 26 live births. Twelve babies were born to women who knew their infection status before delivery. One baby was confirmed to be infected. Six women were given zidovudine for prophylaxis against vertical transmission and none of the babies were infected at birth. Of the remaining 14 human immunodeficiency virus-related pregnancies, the mothers' status became known only at a later date and nine (64.3%) babies were confirmed to be infected at the age of 18 months or older. The rate ratio of giving birth to an infected baby was 8.18 from mothers who did not know their status antenatally. Unlinked anonymous screening showed that the seroprevalence rate for human immunodeficiency virus in pregnant women was 0.032% (1/3125) in Hong Kong in 1999.

CONCLUSIONS

Human immunodeficiency virus-related pregnancy is not rare in Hong Kong and the majority of infected mothers were not identified and treated. Detection of these pregnancies will be invaluable for the prevention of mother-to-child transmission. Universal antenatal screening of human immunodeficiency virus antibody is proposed as an effective strategy.

Differences in clinical and laboratory diagnostic characteristics of penicilliosis marneffei in human immunodeficiency virus (HIV)- and non-HIV-infected patients

We compared the clinical and laboratory features of human immunodeficiency virus (HIV)- and non-HIV-infected patients with penicilliosis marneffei. HIV-infected patients had a higher incidence of fungemia. A total of 85.7% of the HIV-negative patients had underlying diseases including hematologic malignancies or had received therapy with corticosteroids or cytotoxic agents. By a Penicillium marneffei-specific mannoprotein Mp1p enzyme-linked immunosorbent assay, serum antigen titers were found to be higher in HIV-positive patients, whereas serum antibody levels were found to be higher in HIV-negative patients.

Maturational changes in peripheral lymphocyte subsets pertinent to monitoring human immunodeficiency virus-infected Chinese pediatric patients

On the basis of results of testing of 212 peripheral blood samples from ethnic Chinese individuals in five age groups, ranging from birth to adulthood, by standardized flow cytometry techniques, we studied the maturational processes that are pertinent to monitoring the human immunodeficiency virus (HIV)-infected Chinese pediatric population. While the numbers of peripheral total white cells and percent lymphocytes declined from birth to adulthood, the percent CD3+ T lymphocytes was steady among all age groups studied. The numbers of CD3+ CD4+ (T-helper) cells decreased markedly after the first year of life, followed by a slower decline afterward and then a slight increase before adulthood. The trend for CD3+ CD8+(T-suppressor) cells, however, was an increase among individuals of all age ranges. The numbers of CD19+ CD3- (B cells) increased only during the first year of life and then declined steadily, while natural killer (NK) cells showed the opposite pattern. Comparison of the results with those of studies done with a Caucasian population showed that both peripheral T-helper and T-suppressor cell numbers were low after the first year of life in the Chinese pediatric population in comparison with those in a Caucasian pediatric population. Lower B-cell counts and higher NK-cell counts were seen after the first year of life in the Chinese population than in the Caucasian population. It is important that for each HIV-infected population normative ranges of the lymphocyte subset be established to monitor HIV-infected pediatric patients.

Heterogeneity in antifungal susceptibility of clones of Candida albicans isolated on single and sequential visits from a HIV-infected southern Chinese cohort

The increased frequency and severity of candidal infections in human immunodeficiency virus (HIV)-infected individuals has prompted the wide use of antifungals, such as amphotericin B, ketoconazole, and fluconazole, resulting in the emergence of drug-resistant strains of Candida albicans. To study this phenomenon in an ethnic Chinese cohort, we isolated multiple colonies of Candida from the oral cavities of 16 HIV-infected patients on single and subsequent sequential visits over a period of 12 months. Ten of the 16 patients had sporadic episodes of oropharyngeal candidiasis (Group A), while the remainder were asymptomatic with respect to this condition (Group B). Oral rinses were collected and immediately processed in the laboratory for the isolation of C. albicans in a standard manner. A total of 433 C. albicans isolates were tested for their susceptibility to amphotericin B, ketoconazole and fluconazole by an agar diffusion method using the commercially available E-test. All tested isolates demonstrated variable susceptibility to amphotericin B, ketoconazole and fluconazole. The minimum inhibitory concentration (MIC) of the isolates for amphotericin B, ketoconazole and fluconazole ranged from <0.002-1.5 microg/ml, <0.002-4.0 microg/ml and <0.016-32 microg/ml, respectively. Sequential isolates of a few patients demonstrated variable susceptibility to all the antifungals, and no discernible MIC pattern emerged either in group A or B over time. Interestingly, significant variation in antifungal susceptibility was also noted in isolates obtained from the same patient on a single visit. Sequential yeast isolates in 9 of 16 patients (56%) demonstrated significant differences in MIC within and between visits for both amphotericin B and ketoconazole, while a lower percentage--44%(7/16)--exhibited this trait for fluconazole. Our study demonstrates the diversity in antifungal susceptibility in either commensal or "infective" oral strains of C. albicans in HIV disease, and shows the need for vigilance for the emergence of resistant strains, and for frequent antifungal susceptibility studies.

Absolute quantification of regional myocardial uptake of 99mTc-sestamibi with SPECT: experimental validation in a porcine model

We have evaluated a method for absolute in vivo quantification of 99mTc-sestamibi uptake in a porcine model of myocardial perfusion.

METHODS

Correlated CT and radionuclide images were obtained from eight adult pigs using a combined CT-SPECT imaging system. In each case, the CT image is used to generate an object-specific attenuation map that is incorporated into an iterative algorithm for reconstruction and attenuation correction of the radionuclide image. Anatomic information available from the correlated CT image is used to correct the radionuclide image for partial-volume errors by mathematically modeling the radionuclide imaging process. A volume of interest, or template, that approximates the geometric extent of the myocardium is defined from the CT image. Once defined, the template is assigned unit activity and is mathematically projected using a realistic physical model of the radionuclide imaging process including nonideal collimation and object-specific attenuation. The template is then reconstructed from these projections to obtain a pixel-by-pixel partial-volume correction for the myocardium in the radionuclide image. The CT image is also used to delimit the anatomic boundaries of the myocardium for quantification of the radionuclide images. The pixel intensities in the corrected radionuclide image are calibrated in units of activity concentration (MBq/g) and compared with the ex vivo activity concentration measured directly from the excised myocardium.

RESULTS

Without corrections, the measured in vivo activity concentration in the porcine myocardium was only 10% of the true value. Correcting for object-specific attenuation improved the accuracy of this measurement but resulted in values that were still only 42% of the true value. By correcting for both attenuation and partial-volume errors, we were able to achieve absolute quantification with an accuracy error near 10%.

CONCLUSION

We have shown that, by applying object-specific attenuation corrections and suitable partial-volume corrections, absolute regional activity concentration can be measured accurately in the porcine myocardium.

Mandible fractures: a 3-year retrospective study of cases seen in an oral surgical unit in Singapore

A retrospective study of patients referred to the Department of Oral and Maxillofacial Surgery at Singapore General Hospital/National Dental Centre with mandibular fractures over a 3-year period from June 1995 to May 1998 was carried out. The cause, age, sex, race and anatomical distribution of the fractures were analysed for each of the 123 patients. The main cause of trauma was road traffic accidents (RTAs) (35.8%), of which 79.5% were motorcyclists. The highest incidence of trauma was in the 20-29 year age group (46.3%). Males outnumbered females in a ratio of 7.8:1. The parasymphysis was the most common site of injury (30.9%), and combined condylar and parasymphyseal fractures (26.0%) was the most common combination seen.

Surgical treatment of recalcitrant radiation-induced gastric erosions

BACKGROUND

Uncontrolled bleeding as a result of radiation gastritis in patients who have pharyngo-laryngo-esophagectomy and gastric pull-up is seldom reported. Surgical resection in the management of this condition has rarely been described.

METHOD

A 66-year-old man with hypopharyngeal cancer was treated by pharyngo-laryngo-esophagectomy and gastric transposition. He received postoperative radiotherapy and had recurrent hemorrhagic gastritis, necessitating surgical resection. The manubrium was resected to access the mediastinal part of the gastric conduit. The diseased part of the gastric conduit was removed and a free jejunal graft was interposed to replace the resected stomach.

RESULTS

Manubrial resection offered adequate access to the stomach transposed in the mediastinum, and the life-threatening bleeding gastritis was successfully controlled by surgical resection.

CONCLUSION

Surgical resection of the radiation-damaged transposed stomach through a manubrial resection approach can safely be performed. Free jejunal graft is the choice of reconstruction of the circumferential defect.

Rat ovarian interleukin-1alpha: interleukin-1-dependent in vitro expression

Evidence exists supporting the possibility that intraovarian interleukin-1 (IL-1) may play an intermediary role in the periovulatory cascade. Although the existence of a mammalian intraovarian IL-1 system has been convincingly demonstrated, most efforts have focused on the possibility that the mammalian ovary is a site of IL-1b production, reception, and action. The objective of this study was to explore the possibility of ovarian IL-1a expression, characterize its pattern of expression by cultured ovarian cells, and study its hormonal regulation. The basal in vitro expression of IL-1a by cultured whole ovarian dispersates from immature rats increased spontaneously, reaching a peak (sixfold increase over untreated controls) at 4 h. Treatment with an IL-1 receptor antagonist (IL-1RA), human chorionic gonadorropin, or IL-1b failed to attenuate the initial 4-h burst of IL-1a expression. By contrast, treatment of whole ovarian dispersates with IL-1b for 48 h resulted in significant upregulation of IL-1a transcripts (60-fold increase). This IL-1b effect was completely blocked by cotreatment with IL-1RA, thereby suggesting mediation via a specific IL-1 receptor. The IL-1b effect proved to be protein biosynthesis and eicosanoid dependent, nitric oxide independent, and relatively specific in that it was not reproduced by a select series of other granulosa cell agonists.

The identification of credit card encoders by hierarchical cluster analysis of the jitters of magnetic stripes

The relative bit density variation graphs of 207 specimen credit cards processed by 12 encoding machines were examined first visually, and then classified by means of hierarchical cluster analysis. Twenty-nine credit cards being treated as 'questioned' samples were tested by way of cluster analysis against 'controls' derived from known encoders. It was found that hierarchical cluster analysis provided a high accuracy of identification with all 29 'questioned' samples classified correctly. On the other hand, although visual comparison of jitter graphs was less discriminating, it was nevertheless capable of giving a reasonably accurate result.

Low yield of chest radiography in screening for active pulmonary tuberculosis in HIV-infected patients in Hong Kong

This study assessed the usefulness of routine chest radiography for detecting active pulmonary tuberculosis in persons infected with human immunodeficiency virus (HIV) without suggestive symptoms in Hong Kong. Tuberculosis is common in this locality and tuberculosis/HIV co-infection has been a frequent and significant problem. Records of patients attending the largest HIV clinic were reviewed. Three hundred and eleven routine chest radiographs were performed among 191 HIV-infected patients with a total follow-up period of 792 person years. Of the 22 routine chest radiographs that had abnormalities in the lungs or hilar region, only one had led to the diagnosis of pulmonary tuberculosis. No patient with a normal chest radiograph was diagnosed to have tuberculosis within the following 2 months. The low yield (0.32%) suggests that routine chest radiography is not useful in screening for active pulmonary tuberculosis in asymptomatic HIV-infected patients even in a locality where the tuberculosis rate is high.

Low yield of chest radiography in screening for active pulmonary tuberculosis in HIV-infected patients in Hong Kong

This study assessed the usefulness of routine chest radiography for detecting active pulmonary tuberculosis in persons infected with human immunodeficiency virus (HIV) without suggestive symptoms in Hong Kong. Tuberculosis is common in this locality and tuberculosis/HIV co-infection has been a frequent and significant problem. Records of patients attending the largest HIV clinic were reviewed. Three hundred and eleven routine chest radiographs were performed among 191 HIV-infected patients with a total follow-up period of 792 person years. Of the 22 routine chest radiographs that had abnormalities in the lungs or hilar region, only one had led to the diagnosis of pulmonary tuberculosis. No patient with a normal chest radiograph was diagnosed to have tuberculosis within the following 2 months. The low yield (0.32%) suggests that routine chest radiography is not useful in screening for active pulmonary tuberculosis in asymptomatic HIV-infected patients even in a locality where the tuberculosis rate is high.

Indinavir-associated facial lipodystrophy in HIV-infected patients

The objectives of this study were to document the prevalence of facial lipodystrophy in patients with HIV infection receiving protease inhibitors and to identify associated factors. All patients with HIV infection receiving protease inhibitors seen at an HIV clinic in Hong Kong during a 2-month period, from August to October 1997, were assessed for facial lipodystrophy. Among 29 patients who had been receiving indinavir for 3 months or more, facial lipodystrophy was found in 7 (24%). Facial lipodystrophy in these patients was found to be an isolated event and was not associated with noticeable wasting elsewhere. The development of facial lipodystrophy was not found to be associated with age, sex, ethnicity, route of HIV transmission, CD4 cell count, history of AIDS-defining illness, or concurrent anti-retroviral treatment. Facial lipodystrophy was not observed in patients who had received indinavir for less than 3 months. The condition was also not found in patients taking other protease inhibitors, although this could be due to the small sample size. Prospective study of this condition with a larger sample and with objective anthropomorphic measurements would be desirable. In conclusion, facial lipodystrophy is a common occurrence among patients receiving indinavir, and physicians should be alerted to this condition.

Chronic cough in patients with HIV infection

We retrospectively studied the clinical spectrum, course and outcome of 26 patients with HIV infection and chronic cough. All except 2 were homo-/bisexual males. 22 (85%) had AIDS. They had cough for a mean of 75 d with sputum production (88%) and dyspnoea (77%) being the commonest associated symptoms. Sputum examination and chest X-ray were useful initial investigations. CT scan of the chest and sinuses had a high rate of abnormal results for selected patients (89-100%). Cause of cough was found in 21 patients (81%): bronchopulmonary infections (17), Kaposi's sarcoma (5) and sinus infections (3). Patients with sinopulmonary infections tended to have longer duration of cough. Overall, 4 patients (15%) had significant improvement in the illness with cough during the study period. Four patients with bronchopulmonary infections died. We concluded that chronic cough is a heterogeneous clinical problem in advanced HIV-infected patients, most commonly caused by an infective process. Extrapulmonary disease, such as sinusitis, has to be considered and investigated. The clinical course and outcome is unfavourable for most of the patients.

Proposed CD4(+) T-cell criteria for staging human immunodeficiency virus-infected Chinese adults

The present treatment, prophylaxis, and prognostic staging of human immunodeficiency virus (HIV) disease rely heavily on peripheral CD4(+) T lymphocyte (CD4) changes. We correlated the clinical course of events and CD4 changes among consecutive HIV-infected ethnic Chinese adults in Hong Kong. Using death as end point, the estimated proportion survival and death incidences were used to compare CDC and proposed staging criteria based on stratified baseline CD4. A separate set of baseline CD4 per microliter (/microl) (percentage lymphocytes) stratification criteria of 1, >220/microl (>12%); 2, 100-220/microl (6-12%); and 3, <100/microl, (<6%) is proposed which can be used for staging HIV-infected Chinese adults. For our study population, our proposed criteria for stratifying baseline CD4 gave better discrimination and more predictive power than the CDC criteria. We assessed the potential impact of these new proposed criteria on anti-retroviral treatment and prophylaxis against opportunistic infections in our adult HIV-infected population.

Comparing the first and second hundred AIDS cases in Hong Kong

OBJECTIVES

To study the clinical and epidemiological features of the first 200 AIDS patients in Hong Kong.

METHOD

A retrospective analysis of the data reported to the Department of Health. The patients were divided into two groups of first 100 and second 100 cases for comparison so as to discern the temporal changes.

RESULTS

The first 100 AIDS cases were reported from February 1985 through to March 1994 (122 months) while the second 100 in the following 26 months. For both groups, they were predominantly male (94%, 89%), Chinese (66%, 74%) who acquired HIV via sex (83%, 91%). The proportion of Caucasians and homo/bi-sexual contacts in first and second 100 cases have fallen from 26% to 12% (p = 0.012), and from 53% to 31% (p = 0.006) respectively. For primary AIDS-defining illness (ADI), the frequency of Pneumocystis carinii pneumonia (PCP) has decreased (46% to 30%, p = 0.03) while that of tuberculosis (10%, 19%) and Penicillium marneffei (5%, 14%) infection have increased. Mycobacterium avium intracellualare and cytomegalovirus infection have become commoner subsequent ADIs. Frequency of PCP (22%, 9.5%) as the cause of death have dropped while that of tuberculosis has risen (4.8%, 14.3%). Median survival probability had improved from 7.3 months for the first half of patients to 11.9 months for the second half.

CONCLUSION

Incidence of PCP has declined among local AIDS patients whereas tuberculosis, penicilliosis, MAI, and CMV diseases have increased. Survival chance of AIDS patients has improved over the years.

Measurement of anti-dsDNA: a comparative study of two ELISA and the Crithidia assay

We compared the measurement of anti-dsDNA by a commercial ELISA test (DIASTAT), an in-house ELISA and the Crithidia luciliae assay in cross-sectional sera samples of 209 systemic lupus erythematosus (SLE) patients and 64 patients with a variety of rheumatological, autoimmune and non-autoimmune diseases in Hong Kong. The Crithidia assay was found to be the least sensitive (17%) but most specific (95%) method for detection of a positive result in SLE patients. The DIASTAT assay has a higher sensitivity (68%) but lower specificity (80%) than the in-house ELISA test (32% sensitivity and 89% specificity). The positive predictive value of the three assays are comparable at 90-92% while DIASTAT had the highest negative predictive value (44%). There was good linear correlation (r = 0.7) between the two ELISAs. ELISA can serve as a useful screening test for anti-dsDNA in SLE patients and doubtful cases can then be confirmed by another method such as radio-immunoassay.