HIV in practice: current approaches and challenges in the diagnosis, treatment and management of HIV infection in Australia.

As treatment improves, people living with HIV (PLWHIV) can now expect to live longer, which means that the foci of HIV-related care for them and their medical practitioners continue to change. With an increasingly older cohort of patients with HIV infection, practitioners' key considerations are shifting from issues of acute treatment and patient survival to multiple comorbidities, toxicities associated with chronic therapy, and ongoing health maintenance. Within this context, this paper explores the current standard of practice for the management of HIV infection in Australia. We surveyed 56 Australian practitioners currently involved in managing HIV infection: 'HIV section 100' (HIV therapy-prescribing) general practitioners (s100 GPs; n = 26), sexual health physicians (SHPs; n = 24) and hospital-based physicians (HBPs; n = 6). Survey results for practice approaches and challenges were broadly consistent across the three practitioner specialties, apart from a few key areas. s100 GPs reported less prophylaxis use among patients whom they deemed at risk of HIV infection in comparison with SHPs, which may reflect differences in patient populations. Further, a higher proportion of s100 GPs nominated older HIV treatment regimens as their preferred therapy choices compared with the other specialties. In contrast with SHPs, s100 GPs were less likely to switch HIV therapies to simplify the treatment protocol, and to immediately initiate treatment upon patient request in those newly diagnosed with HIV infection. Considerably lower levels of satisfaction with current HIV practice guidelines were also reported by s100 GPs. It appears that greater support for s100 GPs may be needed to address these identified challenges and enhance approaches to HIV practice. Across all specialties, increasing access to mental health services for patients with HIV infection was reported as a key management issue. A renewed focus on providing improved mental health and wellbeing supports is recommended, particularly in the face of an ageing HIV-infected population.

Mycoplasma genitalium: a review.

Mycoplasma genitalium (M. genitalium)was first isolated from the urethral swabs of two symptomatic men with urethritis in 1980. Published prevalence rates vary greatly between populations studied. A number of urogenital conditions have been ascribed toM. genitalium, which is recognised to cause a sexually transmitted infection. The association of M. genitalium with non-specific urethritis is now well established, but the evidence supporting its role in both male and female infertility remains inconclusive. Laboratory methods are challenging and there is a lack of test standardisation. The recommended treatment of the infection is azithromycin as a single 1 gm dose. However, in recent years macrolide resistance has been observed. More studies are required to establish the clinical importance of M. genitaliumin urogenital conditions, particularly infertility, and to establish the role for screening and treatment in high-risk populations.

Seroprevalence of herpes simplex virus types 1 and 2 in HIV-infected and uninfected homosexual men in a primary care setting.

BACKGROUND: Genital herpes is usually caused by herpes simplex virus type 2 (HSV-2), with infections often being unrecognised by patients and/or clinicians. HSV-2 infections may be a risk factor for the transmission of human immunodeficiency virus (HIV) infection. Reliable tests for type-specific HSV antibodies are now readily available. OBJECTIVES: To determine the seroprevalence of HSV-1 and -2 in HIV-seronegative gay men in a primary care setting in Melbourne, Australia, and to compare it with the rate in HIV-infected gay men. To assess the utility in a clinical setting of a type-specific HSV enzyme linked immunosorbent assay (ELISA) as compared with western blot. STUDY DESIGN: We recruited a total of 300 HIV-seronegative homosexual men attending for HIV antibody testing, and HIV-infected men attending for CD4 lymphocyte count and viral load estimation. The subjects completed a questionnaire, and sera were sent for total IgG HSV testing and testing by Gull type-specific HSV ELISA assay. Selected serum samples were retested by western blotting and the results analysed. RESULTS: In total, 168 HIV-antibody negative men and 132 HIV-antibody positive men were recruited. Of all subjects, 73.3% had HSV-1 antibodies. This proportion did not differ between HIV-seronegative and seropositive men (P=0.48). About twenty percent of HIV-seronegative men and 61% of HIV-seropositive men had antibodies to HSV-2 (P<0.0001); 75.6% of HIV-seronegative men with antibodies to HSV-2 gave no history of genital herpes, as did 66.7% of HIV-seropositive men. Overall, in using the type-specific ELISA (Gull) assay, false negative, false positive or equivocal results were obtained in 33/300 (11%) of samples tested compared with western blot. CONCLUSIONS: High rates of HSV-2 infection were found in homosexual males, with the rate for HIV-seropositive men being over twice that for HIV uninfected men. Most subjects were not aware of their infection with HSV-2. HIV-infected individuals were also older and had higher numbers of sexual partners, but we were unable to unambiguously establish that these variables contributed to the difference in HSV-2 seroprevalence rates. The Gull type-specific assay for HSV antibodies has significant problems with sensitivity and specificity at a discrepancy rate of 11%. Caution is advised in using this type-specific commercial assay for clinical purposes.

Urinary tract infections in men in a primary care population.

OBJECTIVE: There have been few studies on urinary tract infections (UTIs) in adult males. This study aimed to look at the clinical features of males presenting with urinary tract infections in a predominantly gay general practice population. METHOD: A retrospective audit and analysis was carried out of all male patients presenting with symptoms suggestive of a UTI and in whom a pathogen was cultured from urine. The subjects were drawn from two urban general practices in Melbourne. Subjects with known pre-existing urinary tract abnormalities, or in whom recent urinary tract instrumentation had been performed, were excluded, as were subjects in whom Neisseria gonorrhoeae was cultured from urine. RESULTS: Thirty-three subjects were identified, with a total of 47 presentations. Six subjects were excluded on the basis of pre-existing known factors which would predispose to UTIs, leaving 27 subjects, with 37 episodes of UTI. The mean age was 43 (range = 28-62) and 25 of the 27 identified as gay. Nine out of the 27 (33%) were HIV positive with a mean CD4 of 574/mm3 (range = 41-1812). The main presenting symptoms were dysuria/burning on micturition, urinary frequency, fever/sweats and haematuria. Urethral discharge occurred in two episodes. Multiple symptoms on presentation were common. The main organism cultured was E. coli. Fourteen subjects underwent further radiological investigation and two abnormalities were detected. CONCLUSION: Uncomplicated UTIs are uncommon in males presenting to general practice. The symptoms are similar to those in females with UTIs, though fever may be more common. Treatment with oral antibiotics in a primary care setting is generally curative. Further investigation of males with UTIs may be appropriate, but more studies are needed as to the cost-benefit of this.

Intraoperative heparin in addition to postoperative low-molecular-weight heparin for thromboprophylaxis in total knee replacement.

The administration of heparin during operation has been reported to enhance the efficacy of thromboprophylaxis in patients undergoing total hip replacement. We have performed a small pilot study in which intraoperative doses of heparin were given in addition to the usual postoperative thromboprophylaxis with enoxaparin in 32 patients undergoing total knee replacement. The primary endpoint was deep-vein thrombosis (DVT) as demonstrated by bilateral venography on 6 +/- 2 days after operation. Sixteen patients developed DVT; in two the thrombosis was proximal as well as distal and in one the occurrence was bilateral. There was one major haemorrhage. These results are similar to those obtained with the use of postoperative thromboprophylaxis with enoxaparin alone. They do not provide support for the initiation of a larger randomised trial of this approach to management.

Mastoid pneumocele causing atlantooccipital pneumatization.

A 49-year-old woman had a palpable mass in her occipital region. Plain radiographs and CT examination revealed extensive atlantooccipital pneumatization with findings consistent with the diagnosis of mastoid pneumocele. Decompression was achieved with placement of a myringotomy tube, resulting in prompt symptomatic relief. On a follow-up CT examination, the pneumatized areas had become opacified and new bone formation was present.

Clinical experience with Hexabrix in cerebral angiography.

Sixty patients from the University of British Columbia, Vancouver General Hospital, and University of Alberta Hospitals Edmonton participated in an open-labelled clinical study on the safety, tolerability and efficacy of ioxaglic acid (Hexabrix) in cerebral angiography. Only 4% of patients experienced significant pain during carotid and brachiocephalic injections of Hexabrix. No increased incidence of side effects or adverse effects were encountered. In addition, radiographic film quality overall was excellent and comparable to that obtained using conventional contrast agents. Hexabrix is a safe and effective contrast agent for cerebral angiography.

Radiation and nitroimidazoles in supratentorial high grade gliomas: a second clinical trial.

As a continuation of a previous controlled trial using "high-dose" metronidazole as a specific sensitizer of hypoxic cells, we used a more efficient nitroimidazole derivative (misonidazole, MISO) in combination with higher doses of radiation in patients with supratentorial high-grade astrocytomas. Sixty-six patients were stratified according to functional level and histological grading, and randomly allocated within 2 weeks of operation of 1 of 3 therapeutic groups: 1, conventional radiation alone; 2, large fractions of radiation with high-dose metronidazole; and 3, radiation as in Group 2 but with equitoxic doses of MISO. We examined survival as the principal end-point of the study. Neither by increasing the dose of radiation over the previous study, nor by using a more efficient sensitizer, were we able to improve survival over the current conventional daily fractionated radiation.

Diagnostic leg scanning for deep venous thrombosis in the recently heparinized patient.

Leg scanning with fibrinogen I 125, either alone on in combination with other procedures, has been proposed as an alternative to venography for diagnosis of deep venous thrombi. Clinical circumstances may necessitate anticoagulation before scanning can be performed, which could alter its reliability. We have compared the results of scanning with venographic findings in heparinized patients with venous thromboembolism. Different criteria for an abnormal leg scan gave different sensitivities and specificities. During the first four days of scanning with a requirement for a persistently abnormal result, five of eight criteria had high specificity (greater than 92%). However, sensitivities did not exceed 55%. With the use of transiently abnormal results and six days of scanning, higher sensitivities were obtained but specificities were reduced. No criterion gave results considered acceptable for a diagnostic test for deep venous thrombosis. Leg scanning should therefore not be used for this purpose in patients who have received anticoagulants. Our results also suggest that duration of symptoms has little effect on the sensitivity of leg scanning and that the test is more reliable for establishing the presence of thrombus than at defining its location.

Fortuitously discovered intracranial aneurysms.

A series of ten patients had 12 intracranial aneurysms fortuitously discovered during roentgenographic investigation for unrelated symptomatology. The benign course of these lesions during a two-year to 7 1/2-year period of observation is of interest.

Complications of cerebral angiography and pneumography.

There were incidences of 0.7% severe and 5.5% mild complications in 1,971 direct puncture carotid angiograms done over a 5-year period. In 1,035 retrograde branchial angiograms, there was a 0.6% incidence of severe, and a 4.7% incidence of mild, complications. Complications tended to increase with increasing age of the patient. Brachial angiography is virtually free of life-threatening complications, and the incidence of neurological sequelae was markedly less than that shown by a comparable analysis of catheter angiography. Of patients undergoing 1,542 fractional pneumoencephalograms, 2 had severe complications.