A rapid and low-cost microscopic observation drug susceptibility assay for detecting TB and MDR-TB among individuals infected by HIV in South India.

Background: The converging epidemics of HIV and tuberculosis (TB) pose one of the greatest public health challenges of our time. Rapid diagnosis of TB is essential in view of its infectious nature, high burden of cases, and emergence of drug resistance. Objective: The purpose of this present study was to evaluate the feasibility of implementing the microscopic observation drug susceptibility (MODS) assay, a novel assay for the diagnosis of TB and multi-drug-resistant tuberculosis (MDR-TB) directly from sputum specimens, in the Indian setting. Materials and Methods: This study involved a cross-sectional, blinded assessment of the MODS assay on 1036 suspected cases of pulmonary TB in HIV-positive and HIV-negative patients against the radiometric method, BD-BACTEC TB 460 system. Results: Overall, the sensitivity, specificity, positive predictive value, and negative predictive value of the MODS assay in detecting MTB among TB suspected patients were 89.1%, 99.1%, 94.2%, 95.8%, respectively. In addition, in the diagnosis of drug-resistant TB, the MODS assay was 84.2% sensitive for those specimens reporting MDR, 87% sensitivity for those specimens reporting INH mono-resistance, and 100% sensitive for specimens reporting RIF mono-resistance. The median time to detection of TB in the MODS assay versus BACTEC was 9 versus 21 days (P < 0.001). Conclusion: Costing 5 to 10 times lesser than the automated culture methods, the MODS assay has the potential clinical utility as a simple and rapid method. It could be effectively used as an alternative method for diagnosing TB and detection of MDR-TB in a timely and affordable way in resource-limited settings.

Spectrum of malignancies among HIV-infected patients in South India.

Introduction: The current study examines the spectrum of malignancies among HIV-infected South Indians enrolled in a clinical care program. Materials and Methods: We conducted a nested matched case-control study among 42 HIV-infected cases who developed cancer and 82 HIV-infected controls between 1998 and 2008 at a tertiary care HIV care program in South India. Results: The most common types of cancer included non-Hodgkin's lymphoma (38.1%), Hodgkin's lymphoma (16.7%), squamous cell carcinoma (14.3%), and adenocarcinoma (14.3%). The median duration of time from HIV infection to cancer diagnosis was 549 days [interquartile range (IQR): 58-2013]. The nadir CD4 cell count was significantly lower in cases compared to controls (134 cells/μl vs. 169 cells/μl; P = 0.015). Cancer patients were more likely to have a more advanced HIV disease stage at the time of cancer diagnosis compared to control patients (Stage C: 90.5% vs. 49.4%; P<0.0001). Significantly more cancer patients were receiving antiretroviral treatment relative to control patients at the time of cancer diagnosis (92.9% vs. 66.3%; P=0.001). Conclusions: HIV-infected patients who developed cancer had more advanced immunodeficiency at the time of cancer diagnosis and a lower nadir CD4 cell count. It is possible that with the continued roll-out of highly active antiretroviral therapy in India, the incidence of HIV-associated malignancies will decrease.

Antiretroviral therapy in Indian setting: When & what to start with, when & what to switch to.

With the rapid scale up of antiretroviral therapy, there is a dramatic decline in HIV related morbidity and mortality in both developed and developing countries. Several new safe antiretroviral, and newer class of drugs and monitoring assays are developed recently. As a result the treatment guideline for the management of HIV disease continue to change. This review focuses on evolving science on Indian policy - antiretroviral therapy initiation, which drugs to start with, when to change the initial regimen and what to change.

Impact of highly active antiretroviral therapy on ophthalmic manifestations in human immunodeficiency virus / acquired immune deficiency syndrome.

Highly active antiretroviral therapy (HAART) has changed the face of human immunodeficiency virus (HIV) acquired immune deficiency syndrome (AIDS) by leading to dramatic decreases in HIV-related morbidity and mortality in the developed as well as developing world. Since the introduction of HAART, the incidence of ocular opportunistic infections causing retinitis has dramatically decreased, and clinicians should be aware of changes in the clinical presentation of ocular manifestations of HIV. As studies of HIV disease after the introduction of HAART continue to become available, more thorough descriptions of treated patients with ocular opportunistic infections will include side-effects and toxicities of therapy. This review focuses on the impact of HAART on the ocular manifestations of HIV.

Financial burden of health services for people with HIV/AIDS in India.

In resource-limited settings, illness can impose a major financial burden on patients and their families. With the advent and increasing accessibility of antiretroviral therapy, HIV/AIDS has now become a fundamentally chronic treatable disease with far reaching economic and social consequences, and hence it is crucial to also examine the long-term financial impact of HIV healthcare. Beyond the direct costs of medications, monitoring, and medical care, additional costs include the long-term lost earnings of HIV-infected individuals as well as of their household members who also provide care. A clearer understanding of the financial burden of healthcare for HIV-infected Indians can allow policy makers and planners to better allocate limited resources. This article reviews the financial consequences of HIV care and treatment on individuals and their households by examining current treatment options, HIV monitoring, the clinical course of HIV disease, and the roles of the private and public sector in providing HIV care in India. Future studies should more thoroughly examine the financial impact of HIV-related costs incurred by households over time and examine household responses to these costs.

Greater severity and extent of periodontal breakdown in 136 south Indian human immunodeficiency virus seropositive patients than in normal controls: a comparative study using community periodontal index of treatment needs.

Apart from the more or less distinctive forms of periodontal disease associated with human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome there remains considerable uncertainty as to whether or not conventional destructive periodontitis is exacerbated in HIV positive individuals. This is especially so in developing countries, from which few studies have been reported. The present study compared the severity and extent of periodontal break down in 136 HIV positive individuals from Chennai, South India, with 136 age-matched controls from the same low socio-economic and ethnic group. All surfaces of all teeth were scored for the community periodontal index of treatment needs (CPITN). Statistical analysis was performed using SPSS package. The results of the present study show that CPITN is a simple, useful technique to assess periodontal status in immunosuppressed patients and that periodontitis is associated with immunosuppression and oral candidiasis. The assessment of periodontal statuscould thus be a useful tool in minimally invasive screening of populations for HIV disease, especially in those parts of the world, like India and Africa, with high prevalence and rising incidence.

Usefulness of an observational database to assess antiretroviral treatment trends in India.

BACKGROUND: Human immunodeficiency virus (HIV) observational cohorts, which are established worldwide, support comparative studies across different regions. They have played an important role in developing international and country-specific HIV treatment and care guidelines. We describe the YRG CARE Chennai HIV observation database (YCHOD) and highlight its utility in monitoring trends in antiretroviral treatment use and HIV disease outcomes in India. METHODS: The baseline characteristics, time trends in antiretroviral treatment, trends in incidence of acquired immune deficiency syndrome (AIDS)-defining illness and mortality following the introduction of highly active antiretroviral therapy (HAART) in India were assessed using YCHOD. RESULTS: Till January 2005, 7647 HIV-positive patients had registered in YCHOD. A majority of the patients were men (69%) and had a mean age of 32 years. At baseline, 14% had an existing AIDS-defining illness. Among patients who required therapy by the WHO criteria, 14% initiated antiretroviral therapy (ART) in 1996 and 35% in 2000. Since the dramatic cost reduction of generic HAART in 2001, there has been an increase in the proportion of patients receiving ART to 57% in 2004. In patients who were started on HAART, the incidence of at least one AIDS-defining illness was 2% in 2001, and this decreased to 0.48% in 2004. CONCLUSION: We feel observational cohorts are useful as a surveillance tool for monitoring trends in treatment and disease progression. Standardized observational data collected systematically on HIV-infected individuals will help to assess the cost-effectiveness of ART and in planning ART strategies for India.

HIV-1 western blot assay: What determines an indeterminate status?

BACKGROUND: The Western blot assay is the gold standard for the detection of antibodies to human immunodeficiency virus type 1 (HIV-1). However, indeterminate Western blot reactivity to HIV-1 proteins may occur in individuals, who may not be infected with HIV. AIM: This retrospective study was aimed to determine the diagnostic value of the interpretation criteria in relation to commercial kits for HIV-1 diagnosis. METHODS AND MATERIALS: A total of 556 serum/plasma specimens collected from high-risk population attending our HIV clinic from 2000-2004 were tested by three different western blot kits: NEW LAV BLOT I (n=244), HIV BLOT 2.2; (n=112), Genetic Systems HIV-1 (n=237). And the results of western blot strips were analyzed using the various interpretation criteria: WHO/NACO, CDC/ ASTPHLD, ARC, FDA, CRSS and JHU. Some specimens were run on more than one kit. RT-PCR assay was performed on 5 specimens, which were indeterminate with LAV BLOT I. RESULTS: The discrepancy in LAV BLOT I positive results were between 157(64)-176(72), and indeterminate results were between 44(18) to 63(25). No such variations were observed in genetic systems. There are some HIV negative (by PCR) specimens were indeterminate in LAV BLOT I revealing the kit more sensitive and less effective for diagnostic purpose. CONCLUSION: The genetic systems kit is superior to other kits we analyzed and its results are concordant with HIV-1 PCR results. To report, the choice of western blot commercial kit is paramount important than the use of particular interpretation criteria for the diagnosis of HIV-1.

Clinical profile of HIV in India.

The clinical course of human immunodeficiency virus (HIV) disease and pattern of opportunistic infections varies from patient to patient and from country to country. The clinical profile of HIV disease in India includes a wide range of conditions like tuberculosis, cryptococcal meningitis, popular pruritic eruptions, and cytomegalovirus retinitis, among others. Tuberculosis is the most common opportunistic infection in Indian patients with HIV. Occurrence of various AIDS-associated illnesses determines disease progression. Mean survival time of Indian patients after diagnosis of HIV is 92 months. In this review, we discuss the clinical profile of HIV disease through an organ system-based approach. With the availability of antiretroviral therapy at lower cost, the clinical profile of HIV disease in India is now changing to include drug-related toxicities and immune reconstitution syndrome.

Clinical manifestations of HIV infected children.

OBJECTIVE: Heterosexual contact is the predominant mode of transmission among adults in India with an increasing number of women of childbearing age becoming infected with HIV. Consequently, children in India increasingly getting infected, primarily from vertical transmission. A retrospective review of the profile of HIV infected children attending an HIV clinic in South India is reported. METHODS: All HIV-infected children under 15 years of age at the time of first presentation and managed at this center between June 1996 and June 2000 are included in this report. Socio-demographic characteristics and clinical manifestation were collected in a precoded proforme. A complete physical examination and baseline laboratory investigations were performed at entry into the clinic and at subsequent follow-up. RESULTS: Fifty-eight HIV-infected children were included: thirty-nine (67.2%) were male with mean age 4 years. Perinatal transmission was the predominant mode of HIV acquisition (67%). Common clinical manifestations in these children at presentation included oral candidiasis (43%), pulmonary tuberculosis (35%), recurrent respiratory infections (26%), bacterial skin infection (21%), papulo-pruritic dermatitis (19%), hepatosplenomegaly and lymphadenopathy (14%) each and chronic diarrhea (7%). CONCLUSION: An understanding of the epidemiology of pediatric HIV infection may reveal opportunities to reduce and perhaps eliminate perinatal transmission. Knowledge of clinical manifestations in this setting will help physicians meet the management challenges presented by HIV infected children.

Current approaches to diagnosis and management of ocular lesions in human immunodeficiency virus positive patients.

Human immunovirus infection in India is rapidly increasing. Ocular lesions due to highly active antiretroviral therapy have been well recognized. Acquired immunodeficiency syndrome can affect all parts of the eye. However, posterior segment lesions are the most common and of these, Human immunodeficiency virus retinopathy and cytomegalovirus retinitis predominate. Often clinical examination can establish the diagnosis of many ocular lesions in acquired immunodeficiency syndrome; therefore, ophthalmologists need to be aware of the more common ones. Various drugs in different routes can used to treat cytomegalovirus retinitis. Highly active antiretroviral therapy has remarkably reduced systemic and ocular morbidity among acquired immunodeficiency syndrome patients. To facilitate care of these patients aseptic precautions for ophthalmic care personnel are now well established and therefore ophthalmologist should not hesitate to provide ophthalmic care to acquired immunodeficiency syndrome patients.

Regression of attained milestones in an HIV infected infant.

We report a case of an 18-month-old child with regression of attained developmental milestones as a manifestation of HIV encephalopathy. This is the first such report in Indian literature. Commencing antiretroviral therapy in this child resulted in arrest of further regression of milestones. This alerts pediatricians to be aware that early developmental delay and regression may be a presenting manifestation of HIV infection in a child.

Multiple cranial nerve palsy in an HIV-positive patient.

We report the case of a 32 -year- old HIV-positive Indian male who presented with sixth nerve (bilateral), ninth, tenth and twelfth nerve palsies; cerebellar and posterior column involvement. CT scan showed gyriform enhancement in the right occipital lobe and nodular leptomeningeal enhancement in the left frontal lobe. Cytomegalovirus serology was positive and the patient was treated as presumed CMV. HIV can present with multiple cranial neuropathy and varied neurological involvement.

Panophthalmitis due to rhizopus in an AIDS patient: a clinicopathological study.

Various opportunistic infections in the eye have been reported earlier in AIDS. We report a case of panophthalmitis in an AIDS patient where the eviscerated tissue on histopathologic and microbiologic examination showed the fungus Rhizopus.

Acute panuveitis with haemorrhagic hypopyon as a presenting feature of acquired immunodeficiency syndrome (AIDS).

Anterior uveitis is a known clinical entity in herpes zoster ophthalmicus associated with AIDS. However, reports of acute haemorrhagic hypopyon uveitis in such cases are lacking. Herein we describe a young male patient presenting with acute panuveitis with haemorrhagic hypopyon, who was found HIV positive on investigation.