Slow Acceptance of Universal Antiretroviral Therapy (ART) Among Mothers Enrolled in IMPAACT PROMISE Studies Across the Globe.

The PROMISE trial enrolled asymptomatic HIV-infected pregnant and postpartum women not eligible for antiretroviral treatment (ART) per local guidelines and randomly assigned proven antiretroviral strategies to assess relative efficacy for perinatal prevention plus maternal/infant safety and maternal health. The START study subsequently demonstrated clear benefit in initiating ART regardless of CD4 count. Active PROMISE participants were informed of results and women not receiving ART were strongly recommended to immediately initiate treatment to optimize their own health. We recorded their decision and the primary reason given for accepting or rejecting the universal ART offer after receiving the START information. One-third of participants did not initiate ART after the initial session, wanting more time to consider. Six sessions were required to attain 95% uptake. The slow uptake of universal ART highlights the need to prepare individuals and sensitize communities regarding the personal and population benefits of the "Treat All" strategy.

Peripheral artery disease in HIV-infected older adults on antiretroviral treatment in Thailand.

OBJECTIVES: HIV infection has become a chronic disease requiring long-term treatment. Premature cardiovascular disease resulting from atherosclerosis in the HIV-infected population has been observed. We assessed the prevalence of peripheral artery disease (PAD), a common consequence of atherosclerosis, in HIV-infected patients aged ≥ 50 years receiving antiretroviral treatment (ART). METHODS: This cross-sectional study was conducted in 12 community hospitals in Chiang Mai, Thailand. Inclusion criteria were as follows: (1) age ≥ 50 years, (2) positive HIV status, and (3) currently receiving ART. Age- and sex-matched hospital patients without documented HIV infection were enrolled as a comparison group. Clinical data were extracted from hospital records. Personal information and details of PAD-related symptoms were obtained through face-to-face interviews. The diagnosis of PAD was made using ankle-brachial index (ABI) measurement. RESULTS: Seven hundred and twenty-four participants were enrolled in the study (362 HIV-infected patients and 362 patients in the comparison group). In the HIV-infected group, 43% were male; the mean (± standard deviation) age was 57.8 ± 5.6 years. The mean (± standard deviation) times from HIV diagnosis and ART initiation were 10.0 ± 4.3 and 8.6 ± 3.5 years, respectively. The prevalence of abnormal ABI (< 1.00) was significantly lower in the HIV-infected group than in the comparison group (20 versus 27%, respectively; P = 0.03), while that of PAD (ABI ≤ 0.90) was not significantly different between the two groups (5 and 7%, respectively). In the HIV-infected group, female sex and low body mass index were independently associated with abnormal ABI. CONCLUSIONS: The prevalence of PAD when measured by ABI in HIV-infected older adults was relatively low. A follow-up study to determine the incidence of PAD and its persistence with time is warranted.

Adverse bone health and abnormal bone turnover among perinatally HIV-infected Asian adolescents with virological suppression.

OBJECTIVES: This study aimed to determine the prevalence of low bone mass and assess its relationship with abnormal bone turnover among HIV-infected Asian adolescents. METHODS: A multicentre, cross-sectional study was conducted at four paediatric HIV centres in Thailand and Indonesia. Perinatally HIV-infected adolescents aged 10-18 years receiving antiretroviral therapy (ART) with virological suppression (HIV RNA < 400 copies/mL) were enrolled. Study assessments included lumbar spine (L2-L4) dual-energy X-ray absorptiometry and measurement of bone turnover markers. Bone mineral density (BMD) and bone mineral apparent density (BMAD) Z-scores were calculated based on Thai normative age- and sex-matched references. Low bone mass was defined as BMD or BMAD Z-scores ≤ -2. RESULTS: Of 396 participants, 57% were female. The median age was 15.0 [interquartile range (IQR) 13.3-16.9] years, and 73% were in Tanner stage 3-5. At enrolment, the median CD4 T-cell count was 734 (IQR 581-907) cells/µL, and 37% were on protease inhibitor (PI)-based regimens. The overall prevalence of lumbar spine BMD and BMAD Z-scores ≤ -2 were 16.4% and 8.3%, respectively. Z-scores were lower with older age, female sex, body mass index (BMI) <5th percentile, boosted PI exposure and CD4 T-cell percentage < 15% before ART initiation. Increased bone turnover markers were inversely associated with BMD and BMAD Z-scores. CONCLUSIONS: Low bone mass was linked to older age, female sex, low BMI, boosted PI exposure, and poor immunological status before ART commencement in our cohort of perinatally HIV-infected Asian adolescents. Dysregulation of bone turnover was associated with bone demineralization. Screening for low bone mass should be implemented to identify individuals who might benefit from interventions to preserve bone health.

Low prevalence of insulin resistance among HIV-infected children receiving nonnucleoside reverse transcriptase inhibitor-based highly active antiretroviral therapy in Thailand.

BACKGROUND: Highly active antiretroviral therapy (HAART) is reported to cause insulin resistance among adults, but effects on children are less clear. We attempted to describe the prevalence of insulin resistance among HIV-infected children receiving HAART. METHODS: Insulin resistance was assessed at 96 weeks of treatment with nonnucleoside reverse transcriptase inhibitor (NNRTI)-based HAART (nevirapine or efavirenz with stavudine and lamivudine) among children in Chiang Mai, Thailand. Insulin resistance was defined as homeostasis model assessment for insulin resistance (HOMA-IR) >/=3.16, fasting c-peptide >/=4.40 ng/mL or fasting insulin >/=25.0 muU/mL. Impaired fasting glucose (IFG) was defined as glucose >/=110 mg/dL. Measurements were analysed for associations with age, lipodystrophy, treatment regimen and clinical data. RESULTS: The prevalence of insulin resistance was 6.5%; no child had IFG. Those with insulin resistance were older with higher body mass index. Children >/=10 years had higher HOMA-IR, c-peptide and insulin, but no difference was seen in the frequency of insulin resistance. No associations between insulin resistance and lipodystrophy or treatment regimen were detected. CONCLUSIONS: Insulin resistance is uncommon among children receiving NNRTI-based HAART and is unrelated to lipodystrophy.

Haematological changes after switching from stavudine to zidovudine in HIV-infected children receiving highly active antiretroviral therapy.

OBJECTIVE: In resource-limited countries, stavudine (d4T) is commonly used as part of the initial highly active antiretroviral therapy (HAART) regimen. Many patients who subsequently develop lipodystrophy switch from d4T to zidovudine (ZDV), a drug that can be myelotoxic. We aimed to study the spectrum and severity of haematological changes following this substitution. METHODS: This was a retrospective cohort study. The inclusion criteria were as follows: HIV-infected children were included who (1) were 2-15 years old at the time of HAART initiation, (2) had not been diagnosed as having haematological diseases, (3) had been receiving a first HAART regimen consisting of either nevirapine or efavirenz, together with lamivudine and d4T, for at least 48 weeks and (4) had switched from d4T to ZDV at least 48 weeks previously. RESULTS: Seventy-eight children were included in the study. Thirty-six (46%) were male. The mean age was 10.3 years (standard deviation 3.1 years). The switch had been made a median time of 65 weeks (range 48-97 weeks) previously. There was no significant change in CD4 lymphocyte count or percentage, or HIV RNA level, after the switch. There was a statistically significant decrease in haemoglobin level (12.6 vs.12.1 g/dL; P<0.001), total white blood cell (WBC) count (8088 vs. 6910 cells/microL; P<0.001) and absolute neutrophil count (ANC) (4320 vs. 3448 cells/microL; P<0.001). However, the decreases never reached Division of AIDS grade 3 or 4 severity, and none of the patients had clinical symptoms or signs of anaemia, leukopenia, or neutropenia. No participant had to discontinue ZDV during the 48-week follow-up period. CONCLUSION: In a paediatric population, statistically significant decreases in haemoglobin level, WBC count and ANC occurred following the substitution of d4T with ZDV, but the magnitudes of the decreases were small and not clinically significant.

Prevalence of protective antibody against measles in HIV-infected children with immune recovery after highly active antiretroviral therapy.

OBJECTIVES: This study was conducted to determine the prevalence of measles-protective antibody in HIV-infected children with immune recovery after highly active antiretroviral therapy (HAART). METHODS: Ninety-six HIV-infected children were enrolled in the study. Their mean age was 9.7+/-2.6 years, 47% were boys, and 47% were in Centers for Disease Control and Prevention (CDC) clinical category C. All participants had been treated with HAART until they achieved a CD4 cell percentage > or =15%. Three children with a history of clinical measles infection were not included in the data analysis. RESULTS: Only 39 out of 93 children (42%) had a measles-protective antibody level, defined as an anti-measles immunoglobulin G (IgG) level > or =320 mIU/mL. There was no significant difference between the groups with and without protective levels of measles antibody in gender, clinical category, age at which HAART was started, duration of severe immune suppression, CD4 cell count and percentage, or plasma HIV RNA level before and after HAART. CONCLUSIONS: We conclude that, despite a history of measles immunization and evidence of immune reconstitution after HAART, many healthy HIV-infected children are still susceptible to measles.