Lowering the dose of hydroxyurea minimizes toxicity and maximizes anti-HIV potency.

The goal of this study was to optimize the hydroxyurea dosage in HIV-infected patients, and to minimize the toxicity and maximize the antiviral efficacy of the hydroxyurea-didanosine combination. In a randomized, open-label study (RIGHT 702, a multicenter trial performed in private and institutional practices), three daily doses (600 microg, 800-900 microg, and 1200 microg) of hydroxyurea were administered in combination with didanosine and stavudine to 115 chronically HIV-infected patients, one-third antiretroviral drug naive, with viremia between 5000 and 200,000 copies/ml regardless of CD4+ cell count. The primary efficacy end point was the proportion of patients with plasma HIV-1 RNA levels below 400 copies/ml after 24 weeks of therapy. In the RIGHT 702 intent-to-treat population the lowest (600 mg) dose of hydroxyurea was better tolerated, associated with fewer adverse events, and more potent by all efficacy parameters, including the primary end point (76 versus 60% patients with viremia<400 copies/ml at week 24 for the 600-mg and 800- to 900-mg dose groups, respectively; p=0.027), the mean area under the curve (60.3 versus 65.8; p=0.016), and the mean log10 decrease (-1.95 versus -0.77; p=0.001). Patients receiving 600 mg of hydroxyurea daily also had the highest CD4+ cell count, CD4+/CD8+ cell ratio, and lowest CD8+ cell count and percentage (p=0.035). The RIGHT 702 trial provides an explanation for the increased toxicity and decreased efficacy of hydroxyurea when it was used at high dosage (1200 mg daily). At the optimal dosage of 600 mg daily, hydroxyurea, in combination with didanosine, deserves reevaluation for the long-term management of HIV/AIDS worldwide, because of its excellent resistance profile, durability, and affordability.

Phosphonoformate (foscarnet): a pilot study in AIDS and AIDS related complex.

Phosphonoformate (PFA; a pyrophosphate analogue) is an effective inhibitor of the reverse transcriptase enzyme in many animal retroviruses. In vitro studies have shown that PFA is also an effective inhibitor of HIV (HTLV III/LAV) at doses readily attainable in vitro. A pilot study was therefore performed with a 3-week intravenous infusion of PFA in 11 patients with AIDS and AIDS-related complex (ARC). Viral isolations were performed before and at regular intervals up to 3 months post-infusion on treated patients, as well as on four untreated control patients. Virus isolation was negative after therapy in eight patients, six of whom were negative throughout the follow-up period. Virus was isolated on 70% of attempts from the four control subjects and on 20% of attempts from treated subjects. Three patients showed an improvement in delayed hypersensitivity responses. No obvious improvement was seen in patients' OKT4 positive lymphocyte counts. Treatment was not limited by side-effects with the exception of one patient who developed an axillary vein thrombosis within 4 days of treatment via a subclavian line. Treatment was therefore discontinued following administration of only one dose and the patient was excluded from further study. A further patient had reversible renal dysfunction. Other side-effects were minor, consisting of headache or thrombophlebitis at the site of infusion. These results suggest that a further trial with PFA administered over a longer period and with a longer follow-up period in AIDS and ARC patients may be warranted, particularly if an oral preparation becomes available.(ABSTRACT TRUNCATED AT 250 WORDS)

The efficacy and safety of zidovudine with or without acyclovir in the treatment of patients with AIDS-related complex. The European-Australian Collaborative Group.

Our objective was to evaluate the efficacy and safety of zidovudine (250 mg every 6 h) alone or in combination with acyclovir (800 mg every 6 h) as treatment for AIDS-related complex (ARC). A double-blind, controlled clinical trial of 6 months therapy was conducted at teaching hospital ambulatory clinics in eight European countries and Australia; 199 patients were studied. Time to development of AIDS-defining opportunistic infections (OI) and AIDS-associated neoplasms, survival, performance status, body weight and CD4+ cell counts were measured. During the study six (9%) zidovudine recipients, five (7%) combination recipients and 12 (18%) placebo recipients developed AIDS-defining OI; the probability of developing an OI was 0.23, 0.09 and 0.08 for the placebo, zidovudine and combination recipients, respectively. Four patients in the placebo group, three in the zidovudine group and one in the combination group died during the study. Patients receiving zidovudine with or without acyclovir had moderate increases in CD4+ cell counts compared with placebo recipients and serum HIV p24 antigen level decreased significantly in all those receiving zidovudine. Fourteen (21%) patients in the zidovudine group and 16 (24%) in the combination group experienced bone-marrow suppression compared with three (5%) placebo recipients. Red-cell transfusions were administered to 6, 19 and 13% of placebo, zidovudine and combination recipients, respectively. These data confirm the efficacy of zidovudine therapy after 4 weeks' treatment in the reduction of development of OI in patients with ARC and support the use of a maintenance dose of 250 mg zidovudine 6-hourly. Given the increased development of OI in the treated groups compared with placebo during the first 4 weeks of therapy, we cannot exclude an initial adverse effect of zidovudine and recommend caution in the use of a loading dose of zidovudine. At 6 months there was no apparent difference in efficacy between the combination of zidovudine and acyclovir compared with zidovudine alone. Moreover, the addition of high-dose acyclovir resulted in a minimal increase in the risk of toxicity.

Dose-escalation, phase I/II study of azithromycin and pyrimethamine for the treatment of toxoplasmic encephalitis in AIDS.

OBJECTIVE: To assess the safety, tolerance and activity of increasing doses of azithromycin in combination with pyrimethamine for the treatment of toxoplasmic encephalitis (TE) in patients with AIDS. DESIGN: A phase I/II dose-escalation study of oral azithromycin in combination with pyrimethamine. SETTING: Eight clinical sites in the United States. PATIENTS: Forty-two adult HIV-infected patients with confirmed or presumed acute TE. METHODS: Patients were enrolled into three successive cohorts receiving azithromycin 900, 1200 and 1500 mg a day with pyrimethamine as induction therapy. The induction period was 6 weeks followed by 24 weeks of maintenance therapy. MAIN OUTCOME MEASURES: Patient response was evaluated clinically and radiologically. RESULTS: Of the 30 evaluable patients, 20 (67%) responded to therapy during the induction period. Ten experienced disease progression. Of the 15 patients who received maintenance therapy, seven (47%) relapsed. Six patients discontinued treatment during the induction period as a result of reversible toxicities. Treatment-terminating adverse events occurred most frequently among the patients receiving the 1500 mg dose. CONCLUSION: The combination of azithromycin (900-1200 mg a day) and pyrimethamine may be useful as an alternative therapy for TE among patients intolerant of sulfonamides and clindamycin, but maintenance therapy with this combination was associated with a high relapse rate. The combination was safe, but low-grade adverse events were common.

Ritonavir and saquinavir combination therapy for the treatment of HIV infection.

OBJECTIVE: To evaluate the safety and antiretroviral activity of ritonavir (Norvir) and saquinavir (Invirase) combination therapy in patients with HIV infection. DESIGN: A multicenter, randomized, open-label clinical trial. SETTING: Seven HIV research units in the USA and Canada. PATIENTS: A group of 141 adults with HIV infection, CD4 T lymphocyte counts of 100-500 x 10(6) cells/l, whether treated previously or not with reverse transcriptase inhibitor therapy, but without previous HIV protease inhibitor drug therapy. INTERVENTIONS: After discontinuation of prior therapy for 2 weeks, group I patients were randomized to receive either combination (A) ritonavir 400 mg and saquinavir 400 mg twice daily or (B) ritonavir 600 mg and saquinavir 400 mg twice daily. After an initial safety assessment of group I patients, group II patients were randomized to receive either (C) ritonavir 400 mg and saquinavir 400 mg three times daily or (D) ritonavir 600 mg and saquinavir 600 mg twice daily. Investigators were allowed to add up to two reverse transcriptase inhibitors (including at least one with which the patient had not been previously treated) to a patient's regimen after week 12 for failure to achieve or maintain an HIV RNA level < or = 200 copies/ml documented on two consecutive occasions. MEASUREMENTS: Plasma HIV RNA levels and CD4+ T-lymphocyte counts were measured at baseline, every 2 weeks for 2 months, and monthly thereafter. Safety was assessed through the reporting of adverse events, physical examinations, and the monitoring of routine laboratory tests. RESULTS: The 48 weeks of study treatment was completed by 75% (106/141) of the patients. Over 80% of the patients on treatment at week 48 had an HIV RNA level < or = 200 copies/ml. In addition, intent-to-treat and on-treatment analyses revealed comparable results. Suppression of plasma HIV RNA levels was similar for all treatment arms (mean areas under the curve minus baseline through 48 weeks were-1.9, -2.0, -1.6, -1.8 log10 copies/ml in ritonavir-saquinavir 400-400 mg twice daily, 600-400 mg twice daily, 400-400 mg three times daily, and 600-600 mg twice daily, respectively). Median CD4 T-lymphocyte count rose by 128 x 10(6) cells/l from baseline, with an interquartile range (IQR) of 82-221 x 10(6) cells/l. The most common adverse events were diarrhea, circumoral paresthesia, asthenia, and nausea. Reversible elevation of serum transaminases (> 5 x upper limit of normal) occurred in 10% (14/141) of the patients enrolled in this study and was associated with baseline abnormalities in liver function tests, baseline hepatitis B surface antigen positivity, or hepatitis C antibody positivity (relative risk, 5.0; 95% confidence interval 1.5-16.9). Most moderate or severe elevations in liver function tests occurred in patients treated with ritonavir-saquinavir 600-600 mg twice daily. CONCLUSIONS: Ritonavir 400 mg combined with saquinavir 400 mg twice daily with the selective addition of reverse transcriptase inhibitors was the best-tolerated regimen of four dose-ranging regimens and was equally as active as the higher dose combinations in HIV-positive patients without previous protease inhibitor treatment.

Toxoplasmosis, an innocuous disease?

This case report should remind physicians that toxoplasmosis may cause serious illness in healthy adults. Difficulties in the differential diagnosis of the disease are discussed.

The acquired immune deficiency syndrome: problems associated with the management of Pneumocystis carinii pneumonia.

Four fatal and two non-fatal cases of pneumonia caused by Pneumocystis carinii and one case of co-trimoxazole-responsive interstitial pneumonia, all in homosexual patients with the acquired immune deficiency syndrome, are described. The lack of clinical signs in the chest and of abnormal radiological findings at presentation in three of the six patients with P. carinii infection, the rapidly progressive course of the disease, as well as the need for early diagnosis and treatment are stressed. The possibility of chemoprophylaxis against P. carinii is discussed.

AIDS: a historical overview.

AIDS has been a recognized clinical entity now for just 10 years. In that time in the United States alone, it is estimated that 1 to 2 million people may be infected with HIV. Estimates of numbers infected worldwide are as high as 10 million. Over these 10 years, considerable progress has been made. The disease and all its protean manifestations have been accurately described. How HIV spreads and where it is spreading have been accurately recorded. The cause is known and well understood, with more detailed information available about HIV than about any other virus. Drugs that slow down the replication of HIV have been discovered and are in widespread use. A cure or vaccine, however, seems unlikely in the near future. The major hope for the present would appear to be continued education to prevent the spread of AIDS and better antiviral agents that will keep HIV suppressed and, ideally, soon allow infected individuals to lead a close-to-normal lifespan (if treatment is commenced at an early-enough stage in the course of the infection).

Challenges of antiretroviral treatment in transient and drug-using populations: the SUN study.

This is an open-label, single-arm, phase 3b study (part of phase 3 development) to evaluate the efficacy and safety of Fortovase-soft gelatin formulation (saquinavir-SGC), combined with zidovudine (ZDV) and lamivudine (3TC), human immune deficiency virus type 1 in (HIV-1)-positive, antiretroviral-naive individuals. Forty-two HIV-1-positive adults with plasma HIV RNA >10,000 copies per milliliter (Roche Amplicor HIV Monitor assay) and CD4 cell count >100 cells/mm(3) were treated with SQV-SGC, 1200 mg three times per day; ZDV, 300 mg; and 3TC, 150 mg each twice per day for 48 weeks. High proportions were drug users (26%), demonstrated psychiatric disorders (alcohol abuse [14%]/depression [14%]), or were inadequately housed (5%). At 48 weeks, 50% of patients achieved viral suppression <400 copies per milliliter with 43% <20 copies per milliliter using an intent-to-treat analysis (missing values counted as virological failures). Corresponding proportions for patients remaining on therapy at 48 weeks were 91% <400 copies per milliliter and 78% <20 copies per milliliter. Most adverse events were mild. Saquinavir-SGC combined with ZDV and 3TC, achieved potent and durable HIV RNA suppression and was well tolerated over 48 weeks in an antiretroviral-naive population including high proportions of individuals considered difficult to treat, such as drug users, people with psychiatric problems and homeless individuals.

Evaluation of a hydrogen peroxide disinfectant for dental unit waterlines.

BACKGROUND: The purpose of this study was to investigate the use of a hydrogen peroxide-based dental unit waterline, or DUWL, treatment to reduce the colonization and growth of heterotrophic bacteria. METHODS: Twenty-three dental units with self-contained water systems were randomly selected. Three of the units and tap water served as controls. Twenty-four water samples were taken at baseline and once a week for five weeks. They were serially diluted, spread-plated in duplicate onto R2A agar plates and incubated at 37 C for seven days. RESULTS: At baseline, the tap water control had a mean count of 0 colony-forming units/milliliter, or CFU/mL, the three control DUWLs had a median count of 8,440 CFU/mL and the 20 treated DUWLs had a median count of 9,760 CFU/mL. By week 1, 19 (95 percent) of the 20 treated DUWLs had counts of less than 200 CFU/mL, and by week 4, the median count for all of the treated DUWLs was 0 CFU/mL. The measurement at week 5 showed that the reduction to below 200 CFU/mL had been maintained. Scanning electron micrographs from processed DUWL tubing samples revealed a similar pattern of results, with biofilm accumulation more evident in the untreated control specimens. CONCLUSIONS: Following the parameters of this study, the authors used a hydrogen peroxide-based disinfectant to achieve the ADA goal of no more than 200 CFU of heterotrophic, mesophilic bacteria per milliliter of unfiltered output water. CLINICAL IMPLICATIONS: An easy-to-use hydrogen peroxide-based DUWL disinfectant demonstrated effectiveness in improving the quality of water used for intraoral procedures. Protocol compliance meets the ADA year 2000 goal.

Many patients suffer from 'battle fatigue': survey.

A new survey underscores the problem of HIV patients' 'battle fatigue,' caused by years of taking antiretroviral drugs and coping with their side effects. AIDS Alert talks with survey consultant Charles F. Farthing, MD, chief of medicine at the AIDS Healthcare Foundation Healthcare Center in Los Angeles and assistant clinical professor of medicine at the University of California at Los Angeles, to discuss the problem of AIDS battle fatigue and summarize the survey's findings.

Adherence and double therapies: an interview with Charles Farthing, M.D. Interview by Marcelo Marer.

AIDS: Charles Farthing, M.D., Director of the AIDS Healthcare Foundation, is interviewed regarding combination antiretroviral therapy and adherence issues. Dr. Farthing is affiliated with the Medical School at University of California at Los Angeles and has been associated with many clinical trials. Farthing believes that it is important to aggressively treat depression with antidepressants in HIV-positive patients. He offers suggestions for dealing with complex drug regimens and increasing the likelihood of adherence. Farthing believes that combination therapies with two protease inhibitors are more tolerable than treatments using just one. He describes strategies for dealing with drug resistance and failing regimens.^ieng

Human immunodeficiency virus infection: a survey with special emphasis on mucocutaneous manifestations.

Since the first reports of acquired immunodeficiency syndrome (AIDS) in 1981, many dermatological conditions have been reported to occur more commonly in people infected with human immunodeficiency virus (HIV). Acute HIV infection may first present as a skin eruption; the onset of immunosuppression after years of infection with HIV may be heralded by the development of various viral, fungal, bacterial, papulosquamous, or neoplastic eruptions. HIV disease often presents first to dermatologists who must be aware of subtle presentations and the possibility of underlying HIV infection--as well as alert to danger signals that indicate the need for urgent treatment or referral.

Two regimens of sultamicillin in treating uncomplicated gonorrhoea.

Sultamicillin is a covalent union of ampicillin and the beta lactamase inhibitor, sulbactam (CP-45,899). Two studies were conducted to assess its efficacy in treating uncomplicated gonorrhoea. In the first study treatment comprised sultamicillin 1.5 g and probenecid 1 g; 124 (89.2%) of 139 patients responded including seven of 11 patients harbouring beta lactamase (penicillinase) producing strains of Neisseria gonorrhoeae (PPNG). In the second study sultamicillin 2.25 g and probenecid 1 g were given; 122 (93.8%) of 130 patients responded. Only two of seven pharyngeal infections resolved, and if pharyngeal infections are excluded the overall cure rate rose to 95.3%. Thirteen of 14 patients infected with PPNG strains were cured by the larger dose. Side effects were mild and transitory. It may be concluded that sultamicillin 2.25 g plus probenecid 1 g is an effective regimen to treat uncomplicated rectal and genital gonorrhoea and is useful for treating infections with PPNG strains. Most beta lactamase resistant antimicrobials must be given parenterally; sultamicillin is given by mouth.

Treatment of cytomegalovirus pneumonitis with foscarnet (trisodium phosphonoformate) in patients with AIDS.

Foscarnet was administered to eight AIDS patients for suspected cytomegalovirus (CMV) pneumonitis as a continuous intravenous infusion for a minimum of 8 days. All the patients improved, three showing complete resolution of symptoms. Evidence of CMV infection from bronchoalveolar lavage samples was lacking in two patients. Adverse drug experiences consisted of thrombophlebitis, transient decreases in haemoglobin concentration, and reversible rises in serum creatinine levels.