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

Comparing the profile of respiratory fungal pathogens amongst immunocompetent and immunocompromised hosts, their susceptibility pattern and correlation of various opportunistic respiratory fungal infections and their progression in relation to the CD4+T-cell counts

Introduction

Invasive fungal infections are increasingly common in the nosocomial setting.

Materials and Methods

The patients were divided into two groups immunocompetent and immunocompromised that is, patients with significant neutropenia <500 neutrophils/μl for longer than 10 days. microscopy, culture, identification of isolates were done and some specilised tests on serum and BAL for antigen detection were performed.

Results

Majority of the patients were young adult males in this study. A higher prevalence of 26.7% was seen in immunocompromised patients. Amongst yeasts, Candida albicans was the predominant species followed by the National AIDS Control that is, Candida glabrata, Candida dubliniensis, Candida parapsilosis and Candida tropicalis in the same order. Amongst moulds, Aspergillus fumigatus was the most common species followed by Aspergillus flavus and Aspergillus niger. Mucor and Penicillium marneffei were seen in a lower prevalence. By Broth microdilution method, isolates of Candida spp. were most sensitive to caspofungin, amphotericin B, ketoconazole and fluconazole in the same order. Isolates of Aspergillus spp. were most sensitive to caspofungin, amphotericin B and itraconazole in the same order. By disc diffusion method, resistance to fluconazole was observed in 6.9% isolates of C. albicans. 50% of C. dubliniensis and 20% of C. glabrata showed resistance to fluconazole. A total mortality of 27.7% was observed during this study. This was distributed as 24.1%, 26.7%, 50%, 50%, 100% and 0% among by patients of candidiasis, aspergillosis, cryptococcosis, pneumocystosis, mucormycosis and penicilliosis. Fifteen per cent were lost to follow-up.

Conclusion

Patterns of invasive fungal infections are changing in many ways. In the midst of these evolving trends, IFI of the respiratory tractcontinue to remain important causes of morbidity and mortality. Diagnostic tools can be adequately used only if the treating physician is aware of the propensity of patients to acquire a fungal infection. Thus, continuous awareness and education is crucial for successful management of patients. Judicious use of antifungal medications as prophylactic measures must be employed, particularly in the critically ill and patients of HIV.

Rate of CD4 decline and HIV-RNA change following HIV seroconversion in men who have sex with men: a comparison between the Beijing PRIMO and CASCADE cohorts

OBJECTIVE

Little is known about the natural history of the HIV infection in men who have sex with men (MSM) in China.

METHODS

We compared changes in CD4+ T-cell count and HIV-RNA following seroconversion before starting antiretroviral therapy between MSM in China and in resource-rich countries using data from the Beijing PRIMO cohort and Concerted Action on SeroConversion to AIDS and Death in Europe (CASCADE), respectively. Linear mixed models were used to compare rates of CD4 decline (cubic root scale) and changes in HIV-RNA (log10 scale) in the first 3 years following seroconversion.

RESULTS

For 131 PRIMO and 3171 CASCADE MSM infected in 2001-2010, estimated CD4+ T-cell count at seroconversion was lower in PRIMO (504 cells/mm3; 95% confidence interval: 463 to 547) compared with CASCADE (554 cells/mm3; 544 to 564). CD4 decline was significantly faster for PRIMO men [-0.59 (-0.72 to -0.47) and - 0.41 (-0.44 to -0.38) cubic root of CD4 count/year for PRIMO and CASCADE, respectively], even after restricting to subtype B (P = 0.01). HIV-RNA at seroconversion was lower in PRIMO compared with CASCADE MSM [difference 0.425 log10/mL (0.249 to 0.603), P < 0.001]. After the first year of seroconversion, PRIMO MSM experienced a faster increase in HIV-RNA [0.830 log10/mL per year; (0.484 to 1.168)] compared with CASCADE MSM [0.018 (-0.035 to 0.067)] (P < 0.001).

CONCLUSIONS

CD4 decline and HIV-RNA increase are faster between MSM in China compared with MSM from resource-rich settings. Whether this is due to differences in host immunity or viral characteristics requires further exploration.

CD4 counts in laboratory monitoring of HIV disease--experience from western India

BACKGROUND

CD4 counts vary in different populations. The present study was conducted to determine CD4 counts in different World Health Organization (WHO) clinical stages in antiretroviral therapy naive individuals and to find out optimum CD4 cutoffs.

METHOD

Data of adult HIV seropositive patients who underwent CD4 count and total lymphocyte count (TLC) testing were included for analysis. The severity of immunosuppression was graded based on WHO criteria. To establish optimum CD4 cutoff values, receiver-operator characteristics (ROC) curves were generated.

RESULTS

Of 754 patients, 52.2% had CD4 counts <200 cells/mm3, but only 2.3% belonged to WHO stage IV. Newer CD4 cutoffs generated were 280, 120-280, <120 cells/mm3. Spearman rank correlation between CD4 counts and TLC was found to be weak (r = .32).

CONCLUSION

The cutoff values of CD4 counts for HIV disease may need to be revised for India. Regular CD4 count estimation is a must for monitoring disease progression in people living with HIV/AIDS.

Development of an HIV Clinical Cohort Database for Enhancing Epidemiologic Surveillance in Hong Kong

The Hong Kong HIV Cohort Database is an observational cohort including all patients enrolled in 2 HIV specialist clinical services in Hong Kong. Basic demographics, HIV transmission category, and the diagnoses of AIDS were captured using a standardized template. As of December 2006, 2132 HIV cases had been registered in the database, representing two thirds of all reports submitted to the government’s surveillance system. Non-Chinese and young females ≤24 years were less represented in the cohort. Description of cohort cases was, however, more complete in terms of transmission category and presentation with AIDS-defining illnesses. Overall, Pneumocystis jirovecci, tuberculosis, and systemic mycosis accounted for a majority of AIDS cases within 3 months of HIV diagnosis. There was a gradual rise of HIV positive men having sex with men in the cohort, notably after 2002, an observation also made in other Asian countries.

Establishing CD4 thresholds for highly active antiretroviral therapy initiation in a cohort of HIV-infected adult Chinese in Hong Kong

Studies on the use and outcome of highly active antiretroviral therapy (HAART) in HIV-infected Chinese have been scarce. We evaluated risk of progression to (1) nonaccidental death and (2) new AIDS-defining illness (ADI) or death in 223, 89.9% of 248 HIV-1-infected adult Chinese patients who were first initiated on HAART between 1997 and 2002, and followed through 2003. The study subjects were mostly male (88.3%), aged between 30-49 years (43.9%), and acquired HIV via sexual contact (95.7%). After a median follow-up of 38.6 months, 13 nonaccidental deaths were observed. Overall, 25 patients developed new ADI or died. Using Kaplan-Meier analyses, there was no survival difference of starting HAART at various CD4 strata but a higher risk of progression to new ADI/death in patients with pretreatment CD4 count less than 100 cells per microliter (p = 0.01). On Cox proportional hazards multivariate regression analyses, pretreatment CD4 counts of less than 100 cells per microliter and less than 150 cells per microliter but not higher levels were the cutoffs for increased progression to death (adjusted hazard ratio [HR] = 4.90, 95% confidence interval [CI]: 1.08-22.22) and new ADI/death (adjusted HR = 14.44, 95% CI: 1.95-106.89), respectively. Age 50 years or greater was the only other independent predictor of mortality and new ADI/death after HAART. Further studies are indicated to validate and discern implications of these preliminary findings of a lower CD4 threshold for antiretroviral therapy in a small Chinese HIV cohort.

CDC staging based on absolute CD4 count and CD4 percentage in an HIV-1-infected Indian population: treatment implications

CD4+ T-cell levels are an important criterion for categorizing HIV-related clinical conditions according to the CDC classification system and are therefore important in the management of HIV by initiating antiretroviral therapy and prophylaxis for opportunistic infections due to HIV among HIV-infected individuals. However, it has been observed that the CD4 counts are affected by the geographical location, race, ethnic origin, age, gender and changes in total and differential leucocyte counts. In the light of this knowledge, we classified 600 HIV seropositive antiretroviral treatment (ART)-naïve Indian individuals belonging to different CDC groups A, B and C on the basis of CDC criteria of both CD4% and CD4 counts and receiver operating characteristic (ROC) curves were generated. Importantly, CDC staging on the basis of CD4% indicated significant clinical implications, requiring an early implementation of effective antiretroviral treatment regimen in HIV-infected individuals deprived of treatment when classified on the basis of CD4 counts.

Validity of existing CD4+ classification in north Indians, in predicting immune status

BACKGROUND

The CD4 lymphocyte count had ethnic variability as observed in many studies. In populations with CD4 counts inherently lower than in the West, the Center for Disease Control and Prevention (CDC) classification system of HIV-infected individuals may not be appropriate. As there is no such criterion currently available for ethnic north Indians HIV-patients, we undertook this study to assess the applicability of the western case definition in north Indian HIV patients.

METHODS

The CD4 counts of 40 normal and 376 HIV-infected north Indian adults attending to ID clinic, SS hospital, Varanasi were estimated by flowcytometry. The mean CD4 counts were estimated and compared between CDC groups A, B and C and controls. Receiver operator characteristic (ROC) curves were generated to determine the cut-off that correlated best with clinical staging for this population.

RESULTS

For CDC groups A, B and C, the mean CD4 counts/mul (upper limits of the 95% CI) were 380.3, 249.2 and 120.9, while the mean CD4 levels in healthy volunteers was 818.4.

CONCLUSION

The mean CD4 count among normal north Indians is significantly lower than that in the western population and parallels that of the Chinese. When categorized based on the Center for Disease Control and Prevention (CDC) classification system, the mean CD4 counts in HIV-infected individuals was lower. Categories of CD4 counts >280, 120-280 and < or =120 cells/microl correlate better with disease progression among HIV-infected individuals. A longitudinal study is required before guidelines for the India population can be devised.

The use of total lymphocyte count (TLC) as an independent criterion for initiating HAART in resource-poor countries

Total lymphocyte count (TLC) is a simple marker for monitoring HIV disease in resource-poor setting. A value of 1.2 x 10(9)l(-1) could be used as an independent criterion for starting antiretroviral treatment, since it is highly predictive of a low CD4 count warranting intervention.

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.