Guidelines for antiretroviral therapy in HIV-1 infected adults and adolescents: the recommendations of the Thai AIDS Society (TAS) 2008.

BACKGROUND: More than 100,000 patients have been treated, since the implementation of the National Universal Coverage for antiretroviral therapy (ART) in Thailand Although there are several comprehensive guidelines available internationally, there is a need to have guidelines that can be implemented in Thailand. MATERIAL AND METHOD: The guidelines were developed by a panel of 17 members who are the experts on HIV research and/or HIV patient care and appointed without incentive by the Thai AIDS Society (TAS). The recommendations were based on evidences from the published studies and availability of antiretroviral agents. Published studies that are relevant and applicable to Thailand in particular have been taken into consideration. RESULTS: The recommendations include: when to start ART; what to start; how to monitor the therapy; adverse effects and its management; diagnosis of treatment failure; and antiretroviral treatment options in patients with treatment failure. ART in special circumstances, i.e., patients with co-infection of tuberculosis or hepatitis B virus, is also included Appropriate level of CD4+ T-cell count to start ART among Thai patients has been considered carefully. The authors recommend to start ART at CD4+ T-cell count < 200 cells/mm3. CONCLUSION: ART should be initiated in adults and adolescents HIV-1 infected patients with a history of HIV-related illness or AIDS or with a CD4+ T-cell count <200 cells/mm3. For treatment-naive patients, the preferred initial therapy is a non-nucleoside reverse transcriptase inhibitor (NNRTI)-based regimen. CD4' T-cell count and viral load should be monitored for at least twice and once a year, respectively. Proper management of antiretroviral-related toxicity and enhancement of adherence are crucial for the long-term success of ART.

Shift work and type 2 diabetic patients' health.

OBJECTIVE: To compare the health between type 2 diabetic patients doing day work and shift work. MATERIAL AND METHOD: Two hundred and forty workers (120 day workers, 120 shift workers) aged 30-60 years were selected from the Social Security Clinic in five hospitals in Bangkok and its vicinity. All participants in the present study filled out the questionnaires that included questions for detecting hypoglycemic symptoms, Thai GHQ--12 questionnaires, and Suanprung Stress Test--20 questionnaires. Fasting blood glucose during the last six months, blood pressure during the last six months, and body mass index (BMI) were collected from the patient's medical records. All results were collected and compared between day workers and shift workers. RESULTS: Good glycemic control was significantly higher in day workers versus shift workers (28.3% vs. 15.8%). A higher proportion of shift workers had hypoglycemic symptoms and abnormal mental health compared to day workers. CONCLUSION: Shift work may have a negative effect on type 2 diabetic patients' health. Consequently, type 2 diabetic shift-worker needs more attention from physicians and employers at their work place.

Lipid profiles of Thai adult HIV-infected patients receiving protease inhibitors.

Dyslipidemia is a common metabolic complication among HIV-infected patients who receive protease inhibitor (PI)-based antiretroviral therapy (ART). In order to assess the prevalence of lipid abnormalities and related factors, a cross-sectional analytic study of the lipid profiles of 170 Thai adult HIV-infected patients receiving PI-containing HAART who attended the HIV-clinic, King Chulalongkorn Memorial Hospital, Bangkok, Thailand between January and August 2005 was conducted. Studied subjects had a median age of 40 years with a median duration of taking PIs of 22.1 months. The mean serum total cholesterol (TC), high density lipoprotein cholesterol (HDL-c), low density lipoprotein cholesterol (LDL-c), and triglyceride (TG) levels were 259.7, 43.7, 135.2, and 506.8 mg/dl, respectively, and the mean TC:HDL-c ratio = 6.4. According to the US National Cholesterol Education Program (NCEP) Adult Treatment Panel III (ATP III) guidelines, high TC, low HDL-c, high TC:HDL-c ratio, high LDL-c, and high TG were found in 52.4, 36.5, 18.8, 44.1, and 42.9%, respectively. Seventy-five subjects (44.1%) were taking lipid-lowering drugs. Only 54 subjects (31.8%) had baseline serum lipid profiles tested before beginning PI. There was statistically significant association between group of PI with serum TC and TG. Subjects taking double boosted and single boosted PI had significantly higher serum TC and TG levels than unboosted PI. Males had significantly higher serum TG levels, while females had significantly higher serum HDL-c levels. Age was significantly associated with serum TC, LDL-c levels, and TC:HDL-c ratios. Serum TC and LDL-c levels were also significantly higher in subjects taking efavirenz.

Occupational exposures among nurses and housekeeping personnel in King Chulalongkorn Memorial Hospital.

OBJECTIVES: To determine the incidence and related factors of blood and body fluid exposure (BBFE)among nurses and housekeeping personnel in King Chulalongkorn Memorial Hospital, Bangkok, Thailand MATERIAL AND METHOD: A retrospective survey of BBFE among 858 nurses and housekeeping personnel who were working in the year 2004 was done. Data were collected by a self-administered questionnaire RESULTS: The annual incidence rate of BBFE was 31.9% (by person) and 45.5 exposures per 100 persons (by event). The highest incidence rate was observed in percutaneous exposure. Graduated nurses had the greatest risk of all exposures, but housekeeping personnel had the highest rate ofpercutaneous exposure. The highest incidence of BBFE was observed in the emergency room. Most BBFE occurred after using a medical instrument. 76.9% of BBFE were not reported. CONCLUSION: The incidence of BBFE among nurses and housekeeping personnel in King Chulalongkorn Memorial Hospital was high. Systematic control measures and good organization of the work and workplace should be urgently implemented.

Physician adherence to isoniazid preventive therapy guidelines for HIV-infected patients in Thailand.

Isoniazid preventive therapy (IPT) has been shown to reduce the risk of active tuberculosis in tuberculin skin test (TST) positive human immunodeficiency virus (HIV) infected individuals. The World Health Organization has recommended IPT for HIV-infected patients since 1999. Physicians' non-adherence to the IPT guideline is one of the limitations to the wide spread use of IPT. A study of the extent to which physicians in Thailand adhere to this guideline will optimize the implementation of national IPT program. Three hundred physicians who provided medical care for HIV-infected patients were sampled by multistage cluster sampling of public hospitals according to the region and the level of health care service. Fifty-eight (19.3%) of the surveyed physicians provided IPT; 86.2% and 34.5% of physicians who provided IPT did not do the TST or screening chest radiography for active TB, respectively. Experience with HIV patient care was significantly associated with providing IPT.

Factors associated with tuberculin skin test reactivity among HIV-infected people in Bangkok.

INH preventive therapy (IPT) has been shown in several randomized controlled trials to reduce the risk of developing active TB in tuberculin skin test (TST) or purified protein derivative (PPD) positive HIV infected individuals. Detection of latent tuberculosis by TST and determination of factors associated with the PPD positivity in HIV-infected persons are important for the targeting of chemoprophylaxis. Six hundred asymptomatic and early symptomatic HIV-infected subjects attending the AIDS Clinic of the Chulalongkorn University Hospital, Bangkok, Thailand were enrolled in two randomized clinical trials of chemoprophylaxis against TB from December 1994 to December 1996. The availability of baseline characteristics, including TST reactivity, among these participants enabled a cross-sectional analysis of factors associated with PPD positivity. The results showed that 117 (19.5%) were PPD positive and 483 (80.5%) were PPD negative with ages 18-65 years (median 29 years). HIV exposure category was 46.2%, 34.5%, and 6.7% for heterosexual contact, commercial sex work, and homosexual and bisexual male contact respectively. The median CD4 cell count was 315/mm3 (range, 5-1,074/mm3). HIV exposure category and CD4 cell count were significantly associated with PPD status. Homosexual/bisexual contact had 3 times higher risk of PPD positivity than heterosexual contact (adjusted OR=2.9; 95% CI, 1.4-6.1) and risk of PPD positivity was higher among patients with CD4 cell counts of 200-500/ mm3 (adjusted OR=1.8; 95% CI, 1.0-3.1) and above 500/mm3 (adjusted OR=3.4; 95% CI, 1.7-6.7) when compared to patients with CD4 cell counts of less than 200/mm3. The HIV-infected persons in Bangkok with homosexual/bisexual contact are at higher risk for latent TB. Population-based tuberculin screening without accompanying HIV testing cannot be used to estimate the prevalence of actual latent TB in a population where HIV infection is widespread, such as in Thailand.

Cost analysis of different types of tuberculosis patient at tuberculosis centers in Thailand.

Tuberculosis (TB) has recently re-emerged as a major public health problem in Thailand. As a consequence of the HIV epidemic in the country, the TB burden has been rising in terms of both morbidity, and mortality which have tremendous socioeconomic impact. However, a study of the cost of various anti-TB drugs in Thailand has never been conducted. A specific aim of this study was to compare the total provider costs of delivering services to different types of TB patient in four zonal TB centers located in the east, northeast, north, and south of Thailand. This aim was accomplished by calculating the unit costs of TB treatment services at these TB centers during the year 1996-1997. All units of the zonal TB centers were classified into 5 cost-center categories: treatment units, laboratory units, radiology units, pharmaceutical units, and administrative/supportive units. The results showed that the average total provider cost of multidrug resistant TB (MDR TB) patients was 89,735.49 baht which was the highest of any type of patient and was 17 times higher than the cost of smear-negative TB cases; this finding was attributed to the high cost of anti-TB drugs for MDR TB cases (65,870 baht), some 95 times higher than the cost for smear-negative cases. Total provider costs were highest in the northeastern region TB centers and lowest in the southern centers for every type of TB patient: smear-negative TB cases (7.727 baht vs 3.916 baht). newly smear positive TB cases (12,539 baht vs 7.020 baht), TB with AIDS cases (15,108 baht vs 8,369 baht). re-treatment TB cases (16,679 baht vs 9,696 baht), and MDR TB cases (102.330 baht vs 82,933 baht). The information from this study may be useful when reviewing the role, function, and cost structure of each TB center in Thailand in order to establish a strategic plan for effective TB control.