[Challenges in HIV long-term care].
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AIDS-Related Opportunistic Infections↗
Biomedical subjects
M Battegay
Publications and source records attributed to M Battegay.
[Therapy of severe fungal infections].
Severe fungal infections increase in numbers in the Western world. This is due to more intensive therapies against cancers leading to severe and prolonged immunosuppression. For many years treatment of severe fungal infections had to be done solely with amphothericin B desoxycholate and 5-fluorocytosine. With the advent of triazoles such as fluconazole, lipid formulations of amphotericin B and the development of echinocandines such as caspofungin also severe candidiasis and invasive aspergillosis has become treatable. In particular, caspofungin for invasive candidiasis and voriconazole for invasive aspergillosis seem at least equivalent to amphotericin B. A clear advantage is the advent of lipid formulations of amphotericin B. This regards especially side effects which are reduced with these newer formulations, i.e. nephrotoxicity. Due to the fact that prospective trials are difficult to conduct because patient populations may vary considerably (especially the underlying disease) many comparisons were not yet performed. Nevertheless, promising results indicate that certain combinations of antifungals may enhance prognosis of refractory fungal infections with a so far very serious prognosis.
Antifungal Agents↗
Gastroenteritis outbreak with norovirus in a Swiss university hospital with a newly identified virus strain.
We report an outbreak of norovirus-associated gastroenteritis in patients and healthcare workers (HCWs) at a university hospital in Switzerland during the period from 28 February to 31 March 2001. Faecal and vomitus specimens and bottled and drinking water were investigated for norovirus by reverse transcriptase-polymerase chain reaction (RT-PCR) Sixty-three patients and HCWs were affected. 37% of the investigated stool specimens were positive for norovirus. Sequencing showed a new phylogenetic strain, "Basel". There was no evidence for a water-borne, foodborne or environmental source. The source of the outbreak was most likely a patient admitted to the hospital. Once an outbreak was suspected, measures were instituted based on published guidelines, such as isolation of patients and excluding sick HCWs from work. However, the application of the guidelines proved difficult. A first realistic goal in such situations is to limit spread of the disease to other areas, specifically to high-risk areas such as intensive care and haemato-oncology units. Optimal management includes a rapid diagnosis of norovirus, written recommendations for management of affected patients and HCWs, and cleaning of surfaces with an effective disinfectant. These recommendations should be available in written form well before such an outbreak is in progress. Such preparations may limit the extent of the outbreak, but norovirus infection in a hospital will probably spread despite infection control interventions.
Aged↗
[Smoking cessation for HIV infected patients].
Cigarette smoking is one of the leading health problems of the general and also of the HIV population. At the HIV clinic at the University Hospital in Basel, Switzerland, many patients expressed the desire to quit smoking. Therefore, an evidence based smoking cessation program was established. The program bases on the two intervention strategies, which have been evaluated as most effective in the state-of-the-art literature: Nicotine substitution and counseling. Counseling bases on dialogues and empowerment. Our smoking cessation program includes a short-term intervention, general information, and a counseling program in several parts. Until recently, in Switzerland, mainly physicians have conducted smoking cessation programs. Moreover, in the German-speaking realm, no publications exist about effective nursing interventions regarding smoking cessation. Thus, the aim of this article is to present an evidence based smoking cessation program offered by both nurses and physicians. Practice experiences indicate that the combination of nicotine substitution and counseling in several parts may be a successful interdisciplinary intervention.
Combined Modality Therapy↗
Effect of highly active antiretroviral therapy on hospitalization characteristics of HIV-infected patients.
In order to determine the impact that highly active antiretroviral therapy (HAART) has on inpatients with HIV infection, HIV-infected patients hospitalized from 1994 to 1999 at the Department of Internal Medicine, University of Basel, Switzerland, were investigated. During the observation period, 578 HIV-related hospitalizations occurred, and 502 charts from 262 different patients were available for evaluation. Analyses showed significant reductions in hospital mortality (from 13.2% to 6.5%) and length of stay for HIV-related admissions (from 16 to 11 days) in the post-HAART period, and the percentage of AIDS-related admissions decreased from 54.5% to 47.6%. However, the admission of HIV-infected patients to the intensive care unit increased from 6.3% to 11.8%, which could indicate that treating physicians have greater confidence in the outcome of HIV-infected patients due to better therapeutic options. Since the advent of HAART, the yearly number of admissions related to HIV dropped by 49% and HAART was administered often during hospital stay. By the end of the study period, death due to multiple HIV-associated diseases and wasting had disappeared.
Antiretroviral Therapy, Highly Active↗
[Mansonella perstans filariasis after stay in Cameroon. A 19-year-old patient born in Cameroon, in Switzerland for the last 10 years].
After a spending three weeks in Cameroon, a 19-year-old woman presented in the emergency room with sudden lancinating pain in the lower abdomen, predominantly on the right side. A blood smear tested for presumed malaria showed subperiodic microfilariae of the species Mansonella perstans. The patient was treated with mebendazole (Vermox).
Adult↗
Disappearance of an intracerebral arteriovenous malformation in an HIV-infected patient after initiation of HAART.
HIV infection or complications of HIV-induced immunodeficiency may affect the central nervous system (CNS). However, vascular cerebral pathologies are very rare, in particular intracerebral arteriovenous malformations (AVM). We report the case of an HIV-infected patient who had a cerebral AVM leading to symptoms such as recurring focal seizures. Only after initiation of potent antiretroviral combination therapy, but not antiretroviral monotherapy or bitherapy, could the viral load be suppressed and immunodeficiency resolved. Two years after the start of highly active antiretroviraL therapy (HAART) total occlusion of the AVM could be demonstrated. Taken together, this case report may demonstrate the potent angiogenic activity of HIV for AVM. Also, this case report might show that inhibition of such a cofactor may lead to resolution of an AVM.
Antiretroviral Therapy, Highly Active↗
Lipodystrophy syndrome by HAART in HIV-infected patients: manifestation, mechanisms and management.
Progressive changes in the distributions of body fat and severe alterations of lipid, glucose and lactate levels challenge the mid and long-term success of highly active antiretroviral therapy of HIV-infection. Both clinical diagnosis of the lipodystrophy syndrome and scientific elucidation of the underlying mechanisms may benefit from a working case definition. In this article, pathophysiological and therapeutic aspects are discussed with reference to physical and metabolic changes. Checkpoints for a practical approach to the patient at risk are given. Specific care and management depend on the predominant alteration, the stage of HIV disease and the medical and antiretroviral history of the individual patient.
Adolescent↗
[Developing and establishing an expanded and more comprehensive HIV/AIDS nursing practice].
Developing and establishing an advanced nursing practice is an essential step toward future-oriented nursing care. An action research process was initiated to establish advanced nursing practice at the HIV clinic of the outpatient department at the University Hospital Basel with the goal to offer advanced nursing care to patients. Participatory action research allows generating knowledge about a social system while at the same time tempts to promote social change. The most important goal is to constantly analyse, improve, and evaluate nursing care for patients and family caregivers. Advanced nursing practice in HIV/AIDS is based on solid knowledge regarding the illness and current therapies. Central concepts are caring, clinical experiences, evidence based practice, and patient preferences. Through a systematic step-by-step process, the nurses at the HIV clinic are being better educated and more experienced in these concepts. An essential aspect of advanced nursing practice is the specialization of each nurse in a self selected topic within HIV/AIDS care. These nurses now offer new services such as medication management and adherence support, health maintenance and prevention, and symptom management. This ongoing process of learning while establishing advanced nursing practice in HIV/AIDS, enables the nurses to face future changes in health care in a proactive way.
Acquired Immunodeficiency Syndrome↗
Ritonavir plus saquinavir versus single protease inhibitor therapy in protease inhibitor-naive HIV-infected patients: the Swiss HIV Cohort Study.
OBJECTIVES: To compare the response to ritonavir (RTV) plus saquinavir (SQV) with single protease inhibitor (PI) therapies among PI-naive HIV-1 infected individuals. METHODS: Response to treatment was analysed according to the intent-to-treat principle in a prospective observational cohort study of 177 patients who between May 1995 and March 2000 started a double PI therapy with RTV and SQV (nonboosting dosages) plus at least one nucleoside reverse transcriptase inhibitor (NRTI) and 2,214 patients with a single PI therapy plus two NRTIs. We used survival analysis and Cox's proportional hazard regression methods. The primary endpoint was the time to a plasma viral load of < 400 copies/mL. Secondary endpoints were taken as a gain in the CD4 count of >100 cells/microL, and change of initial PI for any reason. RESULTS: Baseline characteristics in both treatment groups were balanced. Median follow-up in both groups was 10.4 months. Time to an HIV-1 viral load of < 400 copies/mL and an increase in the CD4 count of >100 x 10(6) cells/L was shorter for RTV plus SQV compared with single PI regimens (log rank test for each endpoint P < 0.05). The adjusted hazard ratios of RTV plus SQV compared with single PI regimens were 1.21 (95% confidence interval 0.99-1.47) for achieving an HIV-1 viral load of < 400 copies/mL, 1.12 (0.88-1.42) for an increase in the CD4 count of > 100 cells/microL, and 0.90 (0.73-1.11) for change of first PI regimen. CONCLUSIONS: Treatment with RTV plus SQV compared with single PI regimens appeared to give similar results for virological or immunological response.
Adolescent↗
[Hospitalizations in a cohort of 175 severely drug-addicted patients of a medically managed opiate withdrawal project].
In this study we investigated a population of 175 seriously drug addicted patients. They were randomised in a controlled opiate maintenance program in Basel, Switzerland. We investigated hospitalizations in the time period three years before entry into the program and approximately 3.5 years after entry into this program. The mean age was 28.4 years, the mean drug injection time was 8.8 years. 82.6% of the patients were seropositive for HCV and 21.5% were HIV-infected. We observed 223 hospitalizations in 100/175 patients during the observation period of 6.5 years. Most commonly infections (n = 94), different diseases of internal medicine (n = 44) and surgical diseases (n = 41) led to hospitalization. Altogether, we found no decrease of the incidence of hospitalisations. However, there was a significant decrease of directly drug-induced diseases (p < 0.05). So far, hospitalizations did not diminish in this well-controlled opiate maintenance program. However, as shown in earlier studies, the incidence of HIV drastically dropped. Hence, it may be that a longer follow-up may prove beneficial regarding the incidence of hospitalisations.
Adult↗
Acute HIV infection: impact on the spread of HIV and transmission of drug resistance.
OBJECTIVE: To assess the impact of primary HIV infection (PHI) on the spread of HIV and the temporal trends in transmission of HIV drug resistance between 1996 and 1999 in Switzerland. METHODS: Sequencing of the genes for reverse transcriptase (RT) and protease was performed for 197 individuals with documented PHI. Phylogenetic analyses were confronted with epidemiological data. RESULTS: Significant clustering was demonstrated for 29% of the RT sequences. All these cases occurred closely together in place and time; contact tracing demonstrated transmission at the time of PHI in 30% of them. Genotypic drug resistance was detected in 8.6% of PHI individuals in 1996, 14.6% in 1997, 8.8% in 1998 and 5.0% in 1999. Drug-resistant variants were identified in 11.3% of individuals infected by homosexual contacts, 6.1% by heterosexual contacts, 13% of intravenous drug users and more frequently in men (10.4%) than women (2.6%). Potential factors involved in the recent decrease of transmission of drug-resistant variants include increase of HIV non-B subtypes from 23% in 1996 to 35% in 1999 (only one non-B subtype had resistance mutations) and a steady increase of patients with undetectable viraemia as documented in Swiss HIV Cohort Study (10% in 1996 vs 53% in 1999). CONCLUSIONS: Phylogenetic and epidemiological analyses underline the impact of PHI in the spread of HIV. Moreover, this study indicates that drug resistance transmission may have decreased recently in Switzerland through the increased frequency of infection with HIV non-B subtypes and the steady increase of patients with undetectable viraemia.
Acute Disease↗
[Vaccinations in adults].
Immunization practices in adults are based on clinical experience and practice. Recent years have seen advances in several viral and bacterial diseases preventable by immunization. The following article discusses general recommendations regarding immunization practices in adults as well as these advances which have modified the current immunization practices. Immunization guidelines for specific diseases are not given in this article. However, they should be looked up in the guidelines for diagnosis and prevention of infectious diseases published by the Swiss Federal Office of Public Health.
Adult↗
Importance of mental health assessment in HIV-infected outpatients.
HIV infection, even when well controlled, may be associated with important mental health problems. We sought to investigate anxiety, depression, and health-related quality of life using screening measurements in patients with HIV infection and to examine their dependency on biosocial parameters relating to HIV. Prospective clinical, virologic, and immunologic data were obtained in a cross-sectional study within the Swiss HIV Cohort Study. Four self-reported questionnaires were used in 397 HIV-infected individuals. The scores for anxiety and depression were high as measured by the Hospital Anxiety and Depression Scale (HADS) and the State Trait Anxiety Inventory (STAI). Half the population scored <75 on a visual analog scale (VAS) Patients were also affected in their quality of life as measured by the HIV Medical Outcome Study (HIV-MOS). Almost all scores were significantly worse for intravenous drug users compared with other transmission groups. People who were employed, with a higher education or with higher CD4 count tended to score better, whereas those who had been hospitalized within the last 6 months, infected for a longer time, with higher viral load, or loss of weight scored significantly worse. A multivariate analysis showed higher education, being employed, low viral load, female gender, and shorter HIV disease duration to be associated with better scores. This study highlights the importance of mental health assessment regardless of HIV-disease parameters.
Adolescent↗
Prevalence of adverse events associated with potent antiretroviral treatment: Swiss HIV Cohort Study.
BACKGROUND: Data on adverse events to antiretroviral treatment have been recorded in clinical trials, post-marketing analyses, and anecdotal reports. Such data might not be an up-to-date or comprehensive assessment of all possible treatment combinations defined as potent antiretroviral treatment. METHODS: Using a standard clinical and laboratory method, we assessed prevalence of adverse events in 1160 patients who were receiving antiretroviral treatment. We measured the toxic effects associated with the drug regimen (protease inhibitor [PI], non-nucleoside and nucleoside analogue reverse transcriptase inhibitor) and specific compounds using multivariate analyses. FINDINGS: 47% (545 of 1160) of patients presented with clinical and 27% (194 of 712) with laboratory adverse events probably or definitely attributed to antiretroviral treatment. Among these, 9% (47 of 545) and 16% (30 of 194), respectively, were graded as serious or severe. Single-PI and PI-sparing-antiretroviral treatment were associated with a comparable prevalence of adverse events. Compared with single-PI treatment, use of dual-PI-antiretroviral treatment and three-class-antiretroviral treatment was associated with higher prevalence of adverse events (odds ratio [OR] 2.0 [95% CI 1.0-4.0], and 3.9 [1.2-12.9], respectively). Compound specific associations were identified for zidovudine, lamivudine, stavudine, didanosine, abacavir, ritonavir, saquinavir, indinavir, nelfinavir, efavirenz, and nevirapine. INTERPRETATION: We recorded a high prevalence of toxic effects attributed to antiretroviral treatment for HIV-1. Such data provides a reference for regimen-specific and compound-specific adverse events and could be useful in postmarketing analyses of toxic effects.
Adult↗
A single-nucleotide polymorphism in the sterol-regulatory element-binding protein 1c gene is predictive of HIV-related hyperlipoproteinaemia.
A single-nucleotide polymorphism (3'322C/G) was identified in the gene encoding a key cholesterol/triglyceride regulator, sterol-regulatory element-binding protein 1c (SREBP-1c). Although it did not alter the amino acid sequence, SREBP-1c-3'322C/G was predictive of highly active antiretroviral therapy-related hyperlipoproteinaemia. Increases in cholesterol were less frequently associated with homozygous SREBP-1c-3'322G (genotype 22) than with heterozygous/homozygous SREBP-1c-3'322C (genotypes 11/12) and correlated with leptin and insulin increases, particularly in genotype 11/12 carriers. A functional mutation linked to SREBP-1c-3'322C/G or messenger RNA conformation differences may explain our findings.
Antiretroviral Therapy, Highly Active↗
[Anemia, neutropenia and thrombocytopenia: hematological findings and HIV].
Hematologic pathologies like anemia, neutropenia and thrombocytopenia are frequently seen in HIV-infected patients. Etiologies of cytopenias are diverse, affect all three cell lines and cause considerable and sometimes even live threatening clinical problems. Opportunistic infections may cause bone marrow suppression or specific cytopenias but also adverse events of antiretroviral drugs and drugs against opportunistic infections frequently cause marrow suppression. Morphological changes in the bone marrow of HIV-infected patients are generally unspecific. Frequently, dysplasia, dyserythropoesis, lymphocyte infiltration or plasmocytosis are seen. In the following article, relevant practical points of pathogenesis and therapy options should be discussed with three case studies.
Adult↗
Sexual transmission during the incubation period of primary HIV infection.
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Adult↗