Early clinical experience of dolutegravir in an HIV cohort in a larger teaching hospital

Dolutegravir (DTG) is the third HIV integrase inhibitor (INI) available for prescription in Belfast since July 2014. It has shown high virological efficacy in both treatment-naïve and -experienced patients. We carried out a retrospective case chart analysis of HIV-1-positive adults commenced on DTG between July 2014 and September 2015. Patients were identified from records as either treatment-naïve or antiretroviral therapy (ART) experienced. Outcomes included: (1) virological response (HIV-1 RNA viral load at 0, 4, 8 and 12 weeks), (2) immunological response (CD4+ cell count at 0, 4, 8 and 12 weeks) and (3) tolerability (side effects and discontinuation). The main exclusion criteria were patients transferring care already established on DTG from other treatment centres or inadequate follow-up information (defined as attendance at <50% of clinical and serological follow-up visits). One hundred and fifty-seven commenced DTG out of 823 patients on ART; 106 (68%) were switched to DTG from another regimen, and 51 (32%) were ART-naïve. One naïve and 14 treatment-experienced patients were excluded from the analysis due to failure to attend clinical follow-up. Analysis of HIV-1 RNA viral load (HIV-1 VL) was divided into three groups: 50 new starters, 68 suppressed at switch and 24 not suppressed at switch. New starters: Baseline median HIV-1 RNA VL 71,259 copies/mL (19,536_Q25-196,413_Q75); 73% were virally undetectable (HIV-1 RNA VL <70 copies/mL) by week 4. Switching patients: Of those with an HIV-1 RNA undetectable viral load prior to switching, two were detectable with a mean viral load of 443,730 copies/mL after four weeks. Of the 24 patients detectable at switch (median HIV-1 VL 2212 [311_Q25-43,467_Q75]), 10 were detectable after four weeks. For those with a recordable viraemia, the median HIV-1 VL reduced to 376 (220_Q25-1181_Q75). At week 12, four patients were detectable with a median VL of 12,390 (567_Q25-52,285_Q75). Overall, 56 (35%) reported side effects; 40 (25%) reported either difficulty with low mood, anxiety or sleep disturbance. Sixteen (10%) discontinued DTG, with 13 (8%) due to intolerable side effects. DTG is a useful drug in naïve or switch patients. It has the potential to effectively suppress the viral load within the first four weeks of treatment and thus reduces infectiousness. Within the cohort, DTG was generally well tolerated but side effects such as low mood, anxiety and sleep disturbance were high, with 8% of patients discontinuing treatment.

A severe hypersensitivity reaction to abacavir following re-challenge

We report this case to highlight the possibility of a severe hypersensitivity reaction as an important potential consequence of couples, living with HIV, sharing anti-retroviral treatment. An HIV-1 positive and carrier of HLA-B*57:01 allele, treatment experienced man was commenced one pill Regimen Stribild (tenofovir, emtricitabine, elvitegravir and cobicistat) in July 2015. On running short of medication, he admitted to sharing his partner's treatment (Triumeq; abacavir, lamivudine and dolutegravir). On the second occasion, re-introduction resulted in whole body rash 4 h post dose and was associated with fever, respiratory symptoms, headache and vomiting. On examination, he was pyrexic, tachyponeic, tachycardiac and hypotensive. Hypersensitivity to abacavir can cause significant morbidity. Re-challenge can result in a more rapid, severe and potentially life-threatening reaction. This potentially could become an increasing problem with more couples, living with HIV, sharing medication.

The syphilis outbreak in Northern Ireland

Since the late 1990s, there has been a resurgence of infectious syphilis, with notable outbreaks in Brighton, Manchester, London and Dublin, predominately among men who have sex with men (MSM). We report a similar outbreak in Northern Ireland. Genitourinary (GU) medicine clinic attendees were assessed from 1 July 2000 to 30 June 2005 to identify those who met the agreed criteria for primary, secondary or early latent syphilis. In total, 161 individuals were diagnosed with syphilis and 121 were MSM. Sixteen individuals indicated a contact in Dublin as the likely source of infection. Thirty were identified through contact tracing. Over half contracted the infection through oral intercourse. Most (106) had one or two partners in the previous three months. Twelve cases were HIV positive (nine were aware of their status at the time of presumed infection). In conclusion, initially, cases acquired their infection in Dublin and, as the outbreak gained momentum, syphilis was contracted within Northern Ireland. The cohort was not generally associated with a high number of sexual contacts, multiple anonymous partners or specific locations. The challenge is to educate both patients and health-care professionals to sexual health issues; specifically, the risk associated with casual oral sex by MSM.

Managing vaccines: defining the remit of primary care and specialist HIV clinics in the delivery of immunization to individuals with HIV infection

The British HIV Association (BHIVA) has published guidelines for immunization of HIV-infected adults. A chart review of 200 HIV-infected patients diagnosed was conducted to determine shortcomings in previous practice and determine which vaccines should routinely be given in specialist HIV clinics and which might be able to be delegated to primary care clinics. Data were collected on administration of three categories of vaccinations: (1) vaccines used in all individuals with chronic disease (pneumococcal, influenza, swine flu H1N1); (2) targeted vaccinations used in non-immune individuals with HIV who are at risk of exposure (hepatitis A and hepatitis B); (3) routine vaccines traditionally delivered to the whole population (measles/mumps/rubella [MMR], diphtheria/tetanus/pertussis and meningitis C/ACWY). Pneumococcal vaccine was delivered to 54% of eligible patients, 52% of eligible individuals completed a full hepatitis B programme of vaccination and 21% (42/200) were naturally immune; hepatitis A vaccine was delivered to 36% of eligible individuals. With increasing demands on resources, it seems likely that HIV services will have to harness resources of primary care in vaccine programmes in relation to routine vaccines. By improving communication between primary and secondary care mistakes with live vaccination decisions could be avoided; HIV services should continue to perform targeted and chronic disease vaccines, i.e. for category 1 and category 2 vaccines.

Post-exposure prophylaxis following sexual exposure to HIV: a seven-year retrospective analysis in a regional centre

An audit of 72 patients presenting for post-exposure prophylaxis following sexual exposure (PEPSE) to HIV (68 genitourinary medicine and 4 accident & emergency) was conducted from 2003 to 2009. The principal indications for PEPSE included 27 (38%) unprotected intercourse (15/27 vaginal and 12/27 anal) with a known HIV-positive partner, 20 (28%) unprotected receptive anal sex with male partner of unknown status, 17 (24%) following sexual assault and three (4%) unprotected sex with a partner from an endemic country. Of those who commenced PEPSE, 92% did so within the recommended 72 hours. Concurrent sexually transmitted infection (STI) was diagnosed in 8.3% patients (6.9% non-gonococcal urethritis and 1.4% rectal chlamydia). Fifty (69%) patients attended for follow-up and only 8% of these did not complete treatment. Twenty-five (35%) patients attended for repeat serology at three months and 18 (25%) at six months. All of the patients followed up remained HIV-negative.

A case of multidrug resistance in the central nervous system

HIV-1 infection may persist in the central nervous system (CNS) despite antiretroviral therapy. We present a case of severe cognitive decline in a man with HIV-1 infection on a fully active regimen for five years. All infective causes were excluded. Despite fully suppressed virus in the blood, HIV RNA in the cerebrospinal fluid measured 3.52 log(10) RNA copies/mL and genotyping of this sample showed an extensive pattern of resistance. This suggested that either the antiretroviral agents were not adequately penetrating the CNS or the CNS had resistant virus as a result of adherence problems. This case highlights the possibility that drug-resistant mutations may develop in the CNS compartment while plasma virus remains suppressed.

Review of low libido in women

Low libido is the most frequently reported sexual dysfunction. This is an important and complex problem with multiple causes. At present the interpretation of data on this topic remains a challenge, as the subject population is diverse and various tools are used in assessment. Coupled with this, several definitions are in use with differing emphasis on distress resulting from this state. Developments in the understanding of psychopharmacology are shedding light on the pathways involved in normal sexual response and these are being utilized in the development of treatments. This article reviews the current definitions, aetiology and treatment options and explores the recent developments in low libido in women.

Self-reported HIV testing practice among physicians treating tuberculosis in Australia and New Zealand

Not all people with tuberculosis have their HIV status ascertained despite the interaction between these infections. We investigated the self-reported HIV testing practice among physicians treating tuberculosis in Australia and New Zealand and used logistic regression to assess factors associated with a routine offer of HIV testing in cases of tuberculosis. Of 290 subjects, 61% always recommended an HIV test for a 38-year-old married man with smear-positive pulmonary tuberculosis. A lower proportion (40%) always tested a 78-year-old man or a female patient (58%), and more always HIV tested a South African case (85%), a patient with oral candidiasis (87%) or an unmarried male patient (66%). No scenario was associated with a universal offer of HIV testing. Clinician factors such as specialty (odds ratio [OR] 3.09), jurisdiction of practice (OR 4.09) and number of HIV tests requested in the past five years (OR 0.29) predicted the self-reported frequency of always HIV testing tuberculosis patients. At least 48% of respondents reported that epidemiological or clinical factors influenced their decision to offer testing. Strategies to increase HIV testing in cases of tuberculosis need to consider clinician factors.

A delayed hypersensitivity reaction to enfuvirtide after rechallenge

Enfuvirtide is beneficial in patients with limited treatment options. We report this case to highlight the possibility of a delayed hypersensitivity reaction as an important potential side-effect of enfuvirtide treatment. A highly antiretroviral treatment-experienced man was commenced on a new regimen containing enfuvirtide. Prophylaxis for Pneumocystis jirovecii pneumonia was started using trimethoprim/sulphamethoxazole (TMP-STX) simultaneously. Ten days later, he developed a maculopapular rash on the chest and abdomen without any systemic features. Both enfuvirtide and TMP-STX were discontinued. Re-introduction of enfuvirtide occurred in a hospital setting. Before re-challenge, haemodynamic observations were stable. The rash re-appeared involving the whole body 5 hours post-dose and was associated with fever (temperature 38.4), nausea and a presyncopal episode. Hypersensitivity to this drug occurred immediately post-dose in phase III trials. Enfuvirtide is a useful drug in those with reduced drug options. The possibility of delayed hypersensitivity has not been reported previously.

Transmission of HIV-1 infection due to a fist fight

Summary

We report a case of HIV-1 infection transmission caused by a fist fight between brothers. A 30-year-old Caucasian UK resident man developed ‘flu-like illness with symptoms of lethargy and weakness. Persistent lymphadenopathy six months later lead to HIV antibody testing, which was positive. Of note, his 37-year-old brother, who was HIV antibody-positive since August 2000, was taking HAART (combivir and nevaripine) with CD4 350 × 106/L (16%) with viral load 4800 copies/mL (log 2.58). A bloody fight had occurred between them four weeks prior to onset of symptoms. Phylogenetic analysis was undertaken. Analysis of the pol gene region indicated that samples from both brothers belonged to the subtype C clade of HIV-1, and that the sequences were closely related to one another. Exposure risk data are extremely useful in helping counsel patients prior to HIV-testing but, as this case illustrates, does not cover all situations.

21. GONORRHOEA INFECTION IN SYDNEY WOMEN

Background: Gonorrhoea is associated with undesirable reproductive health outcomes in women including pelvic inflammatory disease and tubal factor infertility. However there is low prevalence in the general community and some authors have suggested that only those women with risk factors should be tested. But can we predict who will have a positive gonorrhoea result? Methods: A retrospective, case controlled, study was undertaken in an inner Sydney public Sexual Health clinic between January 2000 and December 2005. Cases were all women with culture proven cervical n.gonorrheoea infection in the time period. These were case matched with subsequent women with a negative gonorrhoea culture test. Variables examined included demographics, sex worker status, country of birth, injecting drug use (IDU) status, presence of symptoms and concurrent STIs. Results: There were 40 women who were n.gonorrhoea culture positive during the study period and 27 cases and 23 controls reported any genital symptoms. (what were the confidence intervals?) The relative risk of having gonorrhoea if discharge was described was 1.75 (p�<�0.05). The cases had a high rate of concurrent STI including chlamydia. Conclusions: The only significant predictor of gonorrhoea in this group was the symptom of vaginal discharge. Thus in our clinic population behaviour, demographic data or cannot be used to determine who gets tested for gonorrhoea.