HIV-associated cognitive performance and psychomotor impairment in a Thai cohort on long-term cART.

OBJECTIVES: To assess cognitive performance and psychomotor impairment in an HIV-positive cohort, well-suppressed on combination antiretroviral therapy (cART), in an Asian resource-limited setting. METHODS: Cross-sectional sociodemographic and cognitive data were collected in 329 HIV-positive and 510 HIV-negative participants. Cognitive performance was assessed using the International HIV Dementia Scale (IHDS), Montreal Cognitive Assessment (MoCA), WAIS-III Digit Symbol, Trail Making A, and Grooved Pegboard (both hands). Psychomotor test scores in the HIV-positive participants were converted to Z-scores using scores of the HIV-negative participants as normative data. Psychomotor impairment was defined as performance on two tests more than 1 standard deviation (SD) from controls or more than 2 SD on one test. Multivariate linear and logistic regression analyses were used to investigate associations between HIV and non-HIV-related covariates and poorer cognitive performance and psychomotor impairment. RESULTS: HIV-positive participants, mean age 45 (SD 7.69) years received cART for a median of 12.1 years (interquartile range [IQR] 9.1-14.4). Median CD4 cell count was 563 cells/mm3 (IQR 435-725), and 92.77% had plasma HIV RNA <40 copies/mL. The adjusted mean differences between HIV-positive versus HIV-negative cohorts indicated significantly inferior cognitive performance (tests all P<0.001) with increasing age and lower income, independently associated. Psychomotor impairment was found (P<0.02) in all tests except the Grooved Pegboard non-dominant hand (P=0.48). Psychomotor impairment prevalence was 43% in the HIV-positive cohort, associated with male gender and lower income. CONCLUSIONS: In this study, in individuals with viral suppression rates >90% on long-term cART, we found that inferior cognitive performance and psychomotor impairment were primarily associated with non-HIV-related factors.

Efficacy and safety of a once-daily single-tablet regimen of tenofovir, lamivudine, and efavirenz assessed at 144 weeks among antiretroviral-naïve and experienced HIV-1-infected Thai adults.

OBJECTIVE: To assess the efficacy and safety of a new single-tablet regimen (STR) of tenofovir disoproxil fumarate (TDF) 300mg, lamivudine (3TC) 300mg, and efavirenz (EFV) 600mg in HIV-infected Thai patients. METHODS: This was a prospective study performed for 144 weeks among 51 treatment-naïve patients and 49 experienced patients on separate tablets of TDF, 3TC, and EFV with HIV RNA<50 copies/ml. CD4, HIV RNA, liver and renal function, and lipid profiles were assessed at baseline, weeks 12, 24, and 48, and then every 24 weeks. RESULTS: The median baseline CD4 cell count was 512 cells/µl for treatment-experienced patients and 230 cells/µl for treatment-naïve patients. Median baseline log10 HIV-1 RNA for treatment-naïve subjects was 4.9 copies/ml. From the intention-to-treat (ITT) analysis, the proportion of subjects with HIV RNA <50 copies/ml at week 48, 96, and 144 was 95%, 94%, and 94%, respectively, for antiretroviral-experienced patients and 88%, 90%, and 80%, respectively, for antiretroviral-naïve patients. One virological failure at week 12 had primary drug resistance of K70R, T69D, V75L. Three serious adverse events occurred (tension headache, infective endocarditis, and cervical dysplasia) and another three discontinued the study drug due to EFV intolerance. CONCLUSIONS: This generic STR TDF/3TC/EFV is effective and well-tolerated. These findings lend support to the use of this generic STR as first-line antiretroviral therapy in resource-limited settings.

Attitudes toward, and interest in, the test-and-treat strategy for HIV prevention among Thai men who have sex with men.

This study assessed the attitudes toward, and interest in, the test-and-treat strategy, comprising regular HIV testing and immediate antiretroviral treatment (ART) among men who have sex with men (MSM) in Bangkok, Thailand. A total of 363 participants completed the questionnaires before and after learning about their HIV status. Previous HIV testing reported by 69.8% and 34.7% tested at least annually. Before pretest counseling, 83.2% expressed interest in regular HIV testing and 78.8% in immediate ART. MSM who tested HIV-positive at enrollment were less likely than those who tested HIV-negative to have been tested for HIV before (45.7% vs. 60.8%, p < 0.0001). Among MSM who tested HIV-positive (n = 69, 15.9%), the median level of willingness to take ART immediately increased significantly after learning about their positive results (90 vs.100%, p < 0.0001). Interest in regular HIV testing remained high among HIV-negative MSM after becoming aware of their status (70.9% before vs. 71.9% after, p = 0.55). MSM participants have a strong desire and willingness to start ART immediately upon receiving an HIV-positive test result; it is important to provide the necessary information on the health benefits of early ART and education to the community to maintain their health and prevent HIV transmission.

Diagnosis of gnathostomiasis by skin testing using partially purified specific antigen and total IgE levels.

BACKGROUND: A finding of antibodies to Gnathostoma spinigerum 24-kDa antigen by immunoblot analysis is currently used to confirm a diagnosis of gnathostomiasis. A simple skin test for the diagnosis of gnathostomiasis was developed, and the results were evaluated and compared with the standard Western blot (WB) test. METHODS: This cross-sectional study was conducted at the Hospital for Tropical Diseases, Bangkok, Thailand, in 2008-2011. All eligible patients were tested with partially purified proteins of mAb-detected fractions pooled and sterilized by 0.2 µm diameter syringe filter, with a phenol saline solution of 1:10 w/v. RESULTS: A total of 69 cases, 39 gnathostomiasis cases and 30 controls, were enrolled into the study; the median age (IQR) was 40 (30.5-52.5) years. The most common presenting symptom was edema (56/69, 81%). Gnathostomiasis cases having strong cutaneous reactions to the intradermal test (81%) were also positive by immunoblot. A significant correlation between skin and immunoblot tests was detected (p<0.001). The difference in total IgE levels between cases and controls was not statistically significant (p=0.51). Logistic regression models showed that positive WB and skin-test results were significantly associated with gnathostomiasis (p=0.001 and p=0.007, respectively). CONCLUSION: Gnathostoma skin testing, using prepared fractionated antigen solution of Gnathostoma spinigerum, yields good reactivity and significantly correlates with the results of immunoblot testing.

Issues in women's participation in a phase III community HIV vaccine trial in Thailand.

To assess qualities and outcomes of women participating in a large, community-based HIV vaccine trial, the present study was conducted among female participants of the RV 144 prime-boost trial in Thailand from 2003 to 2009. Qualities of participation refer to complete vaccination, retention, and status change. Outcomes of participation refer to incident rate, adverse event, and participation impact event. A total of 6,334 (38.6%) women participated in the trial, of whom about 50% were classified as low risk and 11% as high risk. About 85% of participants completed four vaccinations and 76% were included in the per-protocol analysis of the on-time vaccination schedule. More women (88%) completed 42 months follow-up compared with men (85%). Women aged 21 and above had more adverse events compared to younger age groups. More women (5%) compared with men (3%) reported participation impact events (PIEs). High-risk women had more PIEs and a higher infection rate compared to the low-risk group. Complete vaccination and retention on last follow-up were more common in married women aged above 21, and being a housewife. Female volunteers showed the same qualities and outcomes of participation as males in the HIV vaccine trial. There was no statistically significant difference in vaccine efficacy between men and women, especially among the high-risk and married women. The study highlighted the important behavioral, social, and cultural issues that could be considered for future HIV vaccine trial designs.

Comparison of clinical outcomes between HIV-infected patients with and without HCV co-infection in a resource-limited setting.

Hepatitis C virus (HCV) co-infection is common among HIV-infected patients; its treatment is not affordable in resource-limited settings. This study aimed to compare the morbidity, mortality, immunological and virological outcomes of antiretroviral therapy (ART) between HIV-infected patients with and without HCV co-infection in a setting where HCV infection is rarely treated. A retrospective cohort study was conducted among HIV-infected patients attending Ramathibodi Hospital between 1998 and 2008. We studied 171 HIV-infected patients 57 with and 114 without HCV co-infection. The mean age of patients was 34.6 years and 67.3% were males. There were no differences in demographics, HIV staging, CD4 counts, ART use and ART regimens between the two groups (p>0.05). All patients who had a CD4 count <200 cells/mm3 or had an AIDS-defining illness during following-up were given ART; these consisted of 84.2% and 88.6% of patients with and without HCV co-infection, respectively. Only 4 out of 57 (7%) HCV co-infected patients were treated for HCV infection. During a median (range) follow-up time of 2.9 (1.2-9.8) years, no patients died in either group. The rates of AIDS-defining illnesses and hospitalization in the two groups were similar (p>0.05). In a resource-limited setting where HCV treatment is not affordable, HCV co-infection does not appear to affect morbidity, mortality or treatment responses to ART. ART may have a greater impact than HCV co-infection on the survival of HCV/HIV co-infected patients. Further studies are needed to assess the long-term impact of HCV co-infection on clinical outcomes in HIV-infected patients without HCV treatment.

Challenges in Providing Treatment and Care for Viral Hepatitis among Individuals Co-Infected with HIV in Resource-Limited Settings.

Hepatitis B and C infections are prevalent among HIV-infected individuals with different epidemiologic profiles, modes of transmission, natural histories, and treatments. Southeast Asian countries are classified as "highly prevalent zones," with a rate of hepatitis B and C coinfection in people living with HIV/AIDS of approximately 3.2-11%. Majority of hepatitis B coinfection is of genotype C. Most of the patients infected with hepatitis C in Thailand have genotype 3 which is significantly related to intravenous drug use whereas, in Vietnam, it is genotype 6. The options for antiretroviral drugs are limited and rely on global funds and research facilities. Only HBV treatment is available for free through the national health scheme. Screening tests for HBV and HCV prior to commencing antiretroviral treatment are low. Insufficient concern on hepatitis-virus-related liver malignancy and long-term hepatic morbidities is noted. Cost-effective HCV treatment can be incorporated into the national health program for those who need it by utilizing data obtained from clinical research studies. For example, patients infected with HCV genotype 2/3 with a certain IL-28B polymorphism can be treated with a shorter course of interferon and ribavirin which can also help reduce costs.

Virologic and Immunologic Outcomes of the Second-Line Regimens of Antiretroviral Therapy Among HIV-Infected Patients in Thailand.

Goal of the second-line therapy among HIV-1-infected patients is to re-establish virological suppression, although treatment options in resource-limited settings are limited. An observational cohort of patients with first-line antiretroviral therapy (ART) failure was conducted in a university hospital in Thailand. Of 95 patients, mean age 39 years, 65% were male. Median CD4 and HIV-1 RNA at second-line ART initiation were 158 cells/mm(3) and 4.1 copies/mL, respectively. Boosted protease inhibitor plus 2 nucleoside reverse transcriptase inhibitors (NRTIs), indicated by genotype results, was commonly used as second-line regimen. At 6, 12, 24, and 36 months of second-line ART, 67%, 62%, 84%, and 90% of patients achieved HIV-1 RNA <50 copies/mL; median CD4 were 258, 366, 444, and 522 cells/mm( 3), respectively. Good adherence, high baseline CD4, and early Centers for Centers for Disease Control and Prevention (CDC) staging were associated with virologic success (P < .05). Second-line ART based on the results of genotype testing yields the good virologic and immunologic outcomes in a resource-limited setting, and scaling-up of second-line ART is indicated.

Anaphylaxis and biphasic phase in Thailand: 4-year observation.

BACKGROUND: Anaphylaxis, a severe systemic allergic reaction, can be fatal. However, its prevalence has been underestimated especially in biphasic phase, due to a lack of case awareness. This study aimed to determine the rate of anaphylaxis, describe clinical manifestations and management, and identify the causative agents and risk factors of biphasic anaphylactic reaction. METHODS: An observational study was conducted at the Emergency Department of Thammasat University Hospital, Thailand, during the period 2004-2008. RESULTS: Of total 208 cases of anaphylaxis identified, the median age was 20.67 years; 52.9% were male. The anaphylaxis rate was 49 per 100,000 patient-years. No fatal case was found; 58.7% had a history of atopy, and 38.5% had experienced a previous allergic reaction, of whom 8.8% had had a previous anaphylactic reaction. The causative allergens were identified in 82.2% of cases; food allergy was most common. Urticaria was the most common presentation (87%). Among 6.3% of the patients who developed biphasic reaction, a significantly longer time from onset of symptoms to administration of epinephrine was detected, with a median of 240 minutes for those with biphasic anaphylaxis, versus 70 minutes for those without (p = 0.002). The median times from onset to hospital arrival and the arrival to administration of epinephrine were also significantly longer in the biphasic group than the non-biphasic patients (p = 0.002 and p = 0.001, respectively). In multivariable regression models, the time intervals from onset and hospital arrival to administration of epinephrine continued to predict biphasic phase occurrence (p < 0.01). CONCLUSIONS: Anaphylaxis predominantly occurs among children and young adults. Delayed administration of epinephrine was associated with the occurrence of biphasic anaphylaxis.

Effectiveness of fixed-dose combination stavudine, lamivudine and nevirapine (GPO-VIR) for treatment of naïve HIV patients in Thailand: a 3-year follow-up.

Generic fixed dose combination stavudine (d4T), lamivudine (3TC) and nevirapine (NVP), named GPO-VIR is recommended in the HIV treatment guidelines for Thailand. The long term effectiveness and adverse effects of this drug combination for the treatment of HIV were evaluated in an ambispective study at Bamrasnaradura Infectious Diseases Institute, Nonthaburi Province, Thailand from March 2002 to January 2006. A total of 152 adult treatment naive HIV patients who had received at least 12 months of GPO-VIR were enrolled. The median (IQR) CD4 cell count increased from 23 (8-94) cells/microl at baseline to 126 (38-180), 136 (98-189), 199 (141-255) and 334 (243-414) cells/microl at 3, 6, 12 and 24 months (p < 0.001), respectively. The median (IQR) percentage of body weights increased from baseline by 3.0% (0.3-6.3), 6.2% (2.2-9.3), 7.3% (3.9-10.9) and 8.1% (3.4-11.9) at 3, 6, 12 and 24 months, respectively and then remained at a plateau until the end of the 3-year study. The occurrence of new opportunistic infections decreased significantly (p < 0.001) with GPO-VIR treatment. Drug resistance occurred in 5 cases (3.3%) with a median (IQR) time of 18.0 (16.5-32.5) months to occurrence. Adverse effects included hypercholesterolemia (43.2%), lipodystrophy (35.5%), hypertriglyceridemia (25%), hypertension (13.1%), peripheral neuropathy (11.9%), hyperlactatemia (2.6%) and lactic acidosis (1.3%). Thirty-six patients (27%) switched from GPO-VIR to other anti-retroviral drugs regimens due to lipodystrophy. This study showed GPO-VIR had clinical and immunological benefits, but one-third of patients had adverse effects.

Immune reconstitution inflammatory syndrome in adult human immunodeficiency virus-infected patients in Thailand.

Immune reconstitution inflammatory syndrome (IRIS) is an important adverse event among human immunodeficiency virus (HIV)-infected patients taking highly active antiretroviral therapy (HAART). The epidemiology of IRIS in Thailand has not been well examined, especially among adult HIV-infected patients. In the present study, we reviewed the medical records of 174 HIV-infected, antiretroviral therapy-naive patients older than 15 years (the median CD4 count at commencement of HAART was 37 cells/mm3) and compared characteristics of patients with and without IRIS. During a 12-month follow-up period after commencement of HAART, 11 cases (6.3%) of IRIS were identified (4.2/100 patient-years HAART). The cases included nine cases with mycobacterial infection, one with cytomegalovirus retinitis and one with cryptococcal meningitis. The patients with IRIS were significantly younger than those without IRIS (29 vs 36 on medians, p = 0.022). The median interval between commencement of HAART and the onset of IRIS was 22 days. Although all patients with IRIS improved with or without corticosteroids, they were more frequently hospitalized during a 12-month follow-up period while taking HAART (1 vs 0 on medians, p < 0.001). The incidence of IRIS in advanced adult HIV-infected patients in Thailand was lower than that reported from Europe and the United States, which may be attributable to deferment of HAART after diagnosing opportunistic infections.

Psychosocial burden of abnormal pap smears among HIV-infected women at Chon Buri hospital, Thailand.

This retrospective case-control study assessed the psychological burden of abnormal Pap smears, and their prevalence and characteristics among HIV-infected women attending an HIV clinic. Women with positive (n = 73) and negative Pap-smear results (n = 317) were assessed for psychosocial burden using 4 questionnaires: Psycho-Social Impact of Abnormal Pap Smears (PEAPS-Q), Hospital Anxiety and Depression Scale (HADS), Work Productivity and Impairment (WPAI) and the EURO-Qol Thermometer. The prevalence of pre-cervical cancer lesions in HIV infected woman was 17.5% (ASCUS 2.9%, LSIL 3.8%, HSIL 7.4%, SCC 1.7%, and atypical glandular cells including adenocarcinoma 1.7%). HIV infected women with abnormal Pap smears showed higher anxiety levels on the HADS questionnaire (p = 0.015); this had a significant effect on regular daily activities (p = 0.009) per the WPAI questionnaire compared to HIV positive women with normal Pap smear. Ever married HIV infected woman with an abnormal Pap smear had a significantly lower psychosocial burden using the PEAPS-Q questionnaire (p < 0.001). After adjusting for age and duration since last Pap smear, the education level of the patient was a strong predictor for anxiety. Patients, with a college education had significantly lower anxiety (p = 0.001, 95% CI -5.74 to -1.37) than those with lower or higher education. Women with HSIL were more anxious (p = 0.014, 95% CI 0.49 -4.39) than those with low grade or normal lesions.

Presence of autoimmune antibody in chikungunya infection.

Chikungunya infection has recently re-emerged as an important arthropod-borne disease in Thailand. Recently, Southern Thailand was identified as a potentially endemic area for the chikungunya virus. Here, we report a case of severe musculoskeletal complication, presenting with muscle weakness and swelling of the limbs. During the investigation to exclude autoimmune muscular inflammation, high titers of antinuclear antibody were detected. This is the report of autoimmunity detection associated with an arbovirus infection. The symptoms can mimic autoimmune polymyositis disease, and the condition requires close monitoring before deciding to embark upon prolonged specific treatment with immunomodulators.

Safety and efficacy of CKBM-A01, a Chinese herbal medicine, among asymptomatic HIV patients.

Complementary remedies represent a potential alternative treatment for chronic diseases, including HIV/AIDS cases not meeting criteria for using highly active antiretroviral therapy (HAART). This study evaluated the safety and efficacy of CKBM-A01, a Chinese herbal medicine, and patient quality of life (QoL). Asymptomatic HIV patients with CD4 counts of 250-350 cells/microl were recruited into this open-labeled trial. Liquid CKBM-A01 was prescribed for a 36-week period. Study participants recorded all symptoms themselves on diary cards. Study parameters, including CD4 cell counts, HIV viral loads, and blood chemistry, were periodically monitored and questionnaires were used to assess QoL and to help with risk reduction. Eighteen volunteers, mean age (+/- SD) 32.07 (+/- 6.88) years, had a median (interquartile range, IQR) baseline CD4 count of 292 (268.50-338.25) cells/microl. No serious drug-related adVerse events due to CKBM-A01 were detected during the study. Intermittent diarrhea was reported in 55.6%, weakness or skin rash/itching in 50%, and increased bowel movement in 33.7%. No significant changes in log viral load or CD4 cell counts were observed at the end of the study. Most of the volunteers (72.2%) expressed satisfaction with CKBM-A01 and had a positive perception. Common colds and nasal symptoms were significantly lower during treatment (p = 0.019). CKBM-A01 appeared to be safe but gave no significant improvement in QoL in asymptomatic HIV patients, and gave no significant improvement in the treatment of HIV based on CD4 cell counts and viral loads.

Pregnancy outcomes among HIV-infected women undergoing antiretroviral therapy.

BACKGROUND: The use of antiretroviral drugs (ARV) to prevent mother-to-child HIV transmission (PMTCT) promises to be effective. However, limited data on the adverse effects of ARV among pregnant women and pregnancy outcomes have been reported in clinical practice. OBJECTIVES: This study aimed to assess adverse effects and outcomes among pregnant HIV-infected women receiving antiretroviral drugs for either antiretroviral therapy (ART) or PMTCT. STUDY DESIGN: This cohort study was at Chonburi Hospital, Thailand, in 2002-2006. RESULTS: A total of 246 pregnant HIV-infected women with the median age (range) of 27 (16-41) years were included in this study. ART was initiated in 16.3% for treatment during ANC, 66.7% for PMTCT during ANC, and 17.1% for PMTCT in labor. Adverse effects, especially anemia, were significantly associated with continuing combined ART in pregnancy (p<0.001). 88.9% delivered normal-term neonates. The prevalence of pre-term delivery was 10.2%. Overall, 24 adverse events from 21 pregnant women (8.5%) were noted. A significantly higher prevalence of pre-term delivery was noted in the groups continuing combined ART, or initiating of PMTCT during labor rather than ANC (p=0.02). The incidence of low Apgar scores was 3.6%, and these were associated with initiation of PMTCT during labor (p=0.004). CONCLUSION: Adverse ARV events were more numerous among the pregnant women who needed ART than PMTCT. ANC is beneficial and strongly recommended for all pregnant HIV-infected women for better pregnancy outcomes.

Predisposing factors for nevirapine toxicity among AIDS patients with low baseline CD4 count.

The objective of the study was to determine the predisposing factors and incidence of toxicity among AIDS patients treated with a nevirapine (NVP)-based regimen in clinical practice. A retrospective cohort study of representative samples of AIDS patients treated with a NVP-based regimen was performed. A total of 206 adult HIV/AIDS cases with median age (IQR) 33 years (range, 29-38 years), 51% male, treated between January 2004-December 2005, were included. Most (92.2%) of the patients were naïve to antiretroviral drug. The incidence of NVP toxicity was 1.09/100 person-months. The median onset time was 4 weeks post NVP initiation (2.57 weeks for skin toxicity and 12.43 weeks for hepatic toxicity). History of drug allergy and NVP toxicity were significantly associated (p = 0.006), as were sulfamethoxazole allergy and toxicity (p = 0.015). Regarding concomitant medication, concurrent anti-tuberculosis drugs significantly increased the risk of NVP associated liver toxicity (p = 0.001). Therefore, it is important to monitor adverse events from NVP, including liver function tests among HIV/AIDS patients with history of drug allergy, especially against sulfamethoxazole, and those concurrently treated with antituberculosis drugs.

Increased interleukin-17 production both in helper T cell subset Th17 and CD4-negative T cells in human immunodeficiency virus infection.

Interleukin (IL)-17 is produced mainly by activated CD4(+) T cells, currently known as Th17. Human immunodeficiency virus (HIV) pathogenesis leads to CD4(+) T cell depletion. This is the first report of IL-17 in HIV infection. We assessed IL-17 expression in the CD4(+) T cells (Th17) of 40 asymptomatic HIV-infected treatment-naive patients compared with 40 HIV-seronegative volunteers. Peripheral blood mononuclear cells (PBMCs), with/without phorbol myristate acetate (PMA)/ionomycin stimulation, were stained with CD3, CD4, IL-17, and interferon (IFN)-gamma antibodies and analyzed by four-color flow cytometry. Both groups had comparable baseline data, except for age (mean+/-SD): 36 +/- 9 versus 30 +/- 9 yr (p= 0.001), CD4(+) T cell counts (median): 218 versus 623 cells/microL (p < 0.0001), CD8(+) T cell counts (median): 875.5 versus 382.5 cells/microL ((p) < 0.0001), and CD4(+)/CD8(+) cell ratios (median): 0.225 versus 1.45 (p< 0.0001). Without stimulation, the percentages of IL-17(+) CD3(+) CD4() and IL-17(+) CD3(+) CD4() cells among HIV-seropositive and -seronegative volunteers (median) were as follows: 0.68 versus 0.12% (p< 0.0001) and 0.92 versus 0.09% (p< 0.0001), respectively. With PMA/ionomycin stimulation, the percent IL-17 expression in CD4(+) cells (median) was 1.45 versus 0.65 (p< 0.0001) and in CD4() T cells it was 1.0 versus 0.12 (p< 0.0001). In conclusion, HIV infection is associated with a significant increase in IL-17 production in both CD4(+) and CD4() T cells in peripheral blood. IL-17 expression was further inducible by PMA/ionomycin stimulation in vitro only in CD4(+) T cells. The roles of IL-17 and Th17 in HIV viral replication and immunopathogenesis are under further investigation.

Comparison of one week with two week regimens of amphotericin B both followed by fluconazole in the treatment of cryptococcal meningitis among AIDS patients.

BACKGROUND: Amphotericin B treatment in cryptococcosis requires daily hospital visits or admission. Its toxicities and hospital costs have been concerned. Short course amphotericin B regimen warrants to be evaluated. OBJECTIVE: To compare the safety and efficacy of one-week (AmB1) with two-week (AmB2) amphotericin B both followed by fluconazole. MATERIAL AND METHOD: 57 AIDS with cryptococcal meningitis were randomly assigned to either AmB1 or AmB2. Microbiological and clinical clearances were the outcomes of the study. RESULTS: The treatment success at 6 weeks was 63.3% in AmB1 and 70.4% in AmB2 (p = 0.574). Clinical assessment at week 10 and renal toxicities were not significantly different between both regimens. Mortality rate was 14% however, 75% of deaths were in AmB2. CONCLUSION: AmB1 was comparably effective and safe as the standard AmB2 regimen in the treatment of AIDS related cryptococcal meningitis. It can be an alternative regimen to lower hospital based care and improve cost effective for source limiting health care centers.

N-acetylcysteine in severe falciparum malaria in Thailand.

One hundred and eight patients with severe falciparum malaria underwent a placebo controlled trial with the antioxidant, N-acetylcysteine (NAC), as an adjunctive therapy along with standard intravenous artesunate therapy. Three NAC dosage regimens were used: an intravenous loading dose of 140 mg/kg followed by 70 mg/kg every four hours intravenously for up to 18 doses (Group 1); a single intravenous loading dose followed by oral NAC in the same amount as for Group 1 (Group 2); a regimen identical to Group 1 except that oral NAC was administered after the first 24 hours (Group 3). Fifty-four patients received placebo plus artesunate. Two critically ill patients died in Group 1. No patient sustained an adverse reaction to the NAC other than vomiting, and the deaths were attributed to severe disease with multiple organ involvement. The excellent results with NAC, the lack of adverse effects, and the rationale for NAC benefit supports the need for a large, double blind trial of NAC as an adjunctive therapy for severe malaria.

6-month evaluation of JinHuang Chinese herbal medicine study in asymptomatic HIV infected Thais.

Good results of in vitro study of anti-HIV effects of JinHuang, a Chinese herbal medicine led to in vivo study of safety and efficacy among asymptomatic HIV infected individuals. It was a prospective open study of 21 asymptomatic HIV infected Thai volunteers. Twelve and 9 were female and male, respectively, with mean age of 29.24 +/- 3.94 years. JinHuang preparation, 6 capsules and 2 bottles of liquid formula orally three times a day, was given on an outpatient basis initially for 6 months. Regular close monitoring and follow-up were done. The side effects reported included : increased bowel movements (81%), vague taste, and smell of drug after initiation (52%). No serious adverse event related to JinHuang was detected during study. No significant changes in terms of log viral load and CD4 count were observed after 6-months' duration. Most of the patients felt that the quality of life was better in terms of better appetite, good sleep and healthy during study participation, however, these were subjective.