Demographic, socio-economic, behavioral and clinical factors predicting virologic failure with generic fixed-dose combination antiretroviral therapy before universal health insurance coverage in northern Thailand.

We conducted a 2-year prospective cohort study to investigate multiple aspects of factors predicting the outcome of fixed-dose combination antiretroviral (ARV) therapy with lamivudine, stavudine, and nevirapine (GPOvir) at a government referral hospital in northern Thailand. At 6 and 24 months after the initiation of GPOvir, viral load (VL) was measured to determine virologic failure (>400 RNA copies/ml) and demographic, socio-economic, behavioral and clinical data were collected. From 10 April 2002 to 31 January 2004, 409 patients participated in this study: 64/364 (17.0%) at 6 months and 55/345 (15%) at 24 months virologically failed treatment. On univariate analysis, besides ARV experience [odds ratio (OR), 3.08, 95% confidence interval (CI), 1.71 -5.57] and the frequency of delayed doses (OR, 2.97; 95% CI, 1.47-6.00), we identified one socioeconomic factor significantly associated with virologic failure: "not having child" (OR, 1.85; 95% CI, 1.03 - 3.34). Although the association with "not having child" became marginal on multivariate analysis, results of in-depth interviews and group discussions indicated that having a child was a strong motivating factor for good treatment compliance. We suggest that patients without children may need more attention. Further investigation of socio-economic factors is warranted.

Mycobacterium avium and Burkholderia pseudomallei (Melioidosis) coinfection in an HIV-positive patient.

A 29 year old HIV positive Thai female with CD4 count of 10 cells/mm3 presented with chronic diffuse abdominal pain, fever, weight loss, anemia and leucopenia. Ultrasonography demonstrated diffuse upper abdominal lymphadenopathy with ascites. Microbiological and molecular work up of the specimen obtained by ultrasound-guided lymph node aspiration revealed co-infection with Burkholderia pseudomallei and Mycobacterium avium. Indirect hemagglutination, IgM-indirect fluorescent antibody, and IgG-indirect fluorescent antibody to Burkholderia pseudomallei were < 1:20, < 1:50 and < 1:50, respectively, at nine months, four months before the culture diagnosis and two months, eight months after the culture diagnosis of Burkholderia pseudomallei infection. The patient was treated initially with two weeks of intravenous ceftazidime, followed by oral cotrimoxazole, doxycycline and chloramphenicol. Clarithromycin and ofloxacin were added after the identification of Mycobacterium avium and its susceptibility test. The patients demonstrated clinical improvement with decreasing abdominal pain and resolution of fever.

Mortality analysis of HIV-1 infected patients for prioritizing antiretroviral drug therapy.

Mortality data of patients, classified according to their clinical status and CD4+ cell count status, would be very useful to guide clinicians to prioritizing patients who need antiretroviral drug therapy. In the current study, the authors re-analyzed data derived from a previously published retrospective study of HIV-1-infected individuals at Lampang Hospital in northern Thailand. According to the Cox proportional hazard model, compared to asymptomatic patients with a high CD4+ cell count (> 200 cell/microl), the mortality rate of asymptomatic patients with a medium CD4+ cell count (100-199 cell/microl) did not significantly differ. However, the mortality rate of patients with a CD4+ cell count below 100 cell/microl was at least 16 times higher, regardless of the presence of clinical symptoms. Based on these results, the authors produced a Lampang Hospital guideline of antiretroviral drug use; priority of antiretroviral therapy should, therefore, be given to patients with CD4+ cell count < 100 cell/microl.