Achieving UNAIDS Viral Suppression Goal: Experience from a Tertiary Care Public Hospital, Western India.

INTRODUCTION: Targeted HIV 1 viral load testing has been recommended in 2010 only for suspected cases of antiretroviral therapy failure. India is committed to achieve UNAIDS '90-90-90' target by 2020. The third 90 target was to ensure all people receiving antiretroviral therapy (ART) are virologically suppressed. Implementation of routine viral load testing in national programme helps us in assessing early treatment failure and the need to switch to second line therapy; thus eventually reducing drug resistance and improving patient outcomes. AIMS: Study was aimed to determine the proportion of patients responding to antiretroviral therapy, correlates of viral suppression & the discordance between virological and immunological failure. DESIGN: Retrospective analysis. MATERIAL & METHODS: As per the NACO policy, all patients diagnosed as HIV positive are started on antiretroviral therapy and are monitored regularly. The patient's adherence details are noted down during regular follow up visit and patient is referred for routine HIV 1 VL and/or CD4 testing as per National guidelines. Analysis of data was carried out retrospectively for all patients referred for HIV 1 viral load and/or CD4 testing during the study period from July 2019 to June 2020. Confidentiality of the patient was maintained at all times as per routine protocol. RESULTS: A total of 7601 PLHIV on antiretroviral therapy, 3813 samples were tested for both HIV 1 VL and CD4 counts and these results were further analyzed. 3616 (94.8%) showed virological suppression and 197(5.2%) showed virological failure. Among virologically failed group, 46.2% (91/197) underwent retesting after adherence counseling and among these 48.4%(44/91) showed viral suppression. Virological failure was significantly high in younger PLHIV receiving second or third line ART for less than 5 years duration who were non adherent. Immunological discordance was seen in 28.3 % of PLHIV. CONCLUSION: In the present study, 95.99% patients showed virological suppression indicating that the third "90"target is being exceeded.

Microparticles as prognostic biomarkers in dengue virus infection.

Promising biomarkers which may help predict the risk of developing severe dengue virus infection (DVI) are lacking and will be helpful. Thus the main aim of this study was to analyze the role of cell-derived microparticles (MP) in DVI. Sixty patients with DVI i.e. 18: dengue with warning signs (DWS); 1: DSS and 41: dengue without warning signs (DWOS); along with 15 controls (other febrile illness) were included in the study. The following MPs were assessed: annexinV, platelet (CD41a), red blood cell (RBC) (CD235a) and activated endothelial (CD62e) MPs. Patients with profound thrombocytopenia without bleeding had statistically elevated platelet MP (PMP) levels when compared to patients with profound thrombocytopenia with bleeding (p < .001). RBC MPs were found to be significantly elevated in the 2nd phase in patient with DWS which was seen earliest on day 4 of infection with a cut off of ≥2200 MPs/µl when compared to patients with DWOS (p < .0001). PMPs may prove to be a promising novel biomarker which helps discriminate patients in need of prophylactic platelet transfusion from those who do not. RBC MPs, on the other hand could be potential biomarkers capable of identifying potentially severe patients who require immediate care. Thus, MPs seem to be a promising important biomarker in many aspects of DVI.

Double - Trouble- Relapsing Leishmaniasis in a Virologically Suppressed HIV Positive Patient.

We present a case of a middle aged male, with long standing retroviral disease on second line ART (Anti-Retroviral Therapy) with three episodes of visceral leishmaniasis diagnosed on bone marrow examination treated with a combination of liposomal amphotericin B and miltefosine.

Hepatotoxicity in HIV Patients, An Observational Study in Patients from Tertiary Care Centre of Western India.

OBJECTIVE: HIV AIDS has currently become a chronic manageable condition with HAART, but with its chronicity and lifelong therapy currently the adverse drug reactions to these drugs are the main concern for any treating physician. Hepatotoxicity is one of the prime concerns of any physician managing HIV patients. We observe a number of patients reporting hepatotoxicity in our cohort and this had great impact on the efficacy and intake of the HAART drugs, this led us to explore this area and to find out the prevalence and etiologies in our cohort. METHODS: Thus we conducted this observational study to determine the prevalence of hepatotoxicity, the various etiologies for hepatotoxicity and assess HAART as the etiology of hepatotoxicity .The study was conducted in the virology department after obtaining ethics committee approval and incompliance with ICH, GCP guidelines. The study was conducted over a span of 3 months and data was collected and analyzed. RESULTS: Data of 178 Subjects was considered for evaluation of which 10 were excluded due to incomplete information. 168 patients with hepatotoxicity were assessed in the study, the prevalence of hepatotoxicity in our cohort was around 2.25%. Of the 168 patients 111 were male and 57 were female.52 patients were on Antituberculosis therapy (ATT) and thus 30.95% was the incidence rate of hepatotoxicity due to ATT. 23.80% (40 out of 168) were alcoholic and hence it was the etiological agent. HAART as the etiology was observed in 5 patients,2.97%being the incidence .Hepatitis B as the causative agent for hepatotoxicity was observed in 3.57% patients. CONCLUSIONS: We thus concluded that ATT and alcoholism are major areas of concern in HIV patients and thus a strict monitoring is warranted while prescribing ATT at the same time deaddiction is equally important. HAART induced hepatotoxicity is observed only in a small section of patients and thus these drugs need not be attributed as culprits blindly and put to disrepute.

Zika Virus Infection, the Recent Menace of the Aedes Mosquito.

Mosquito-borne infections and viral outbreaks have bewildered physicians and population at large from time to time, there seems to be a constant cat and mouse race between the medical fraternity and these mosquito menaces. Zika virus and its vector Aedes aegyti are currently bothering the world population, this infection has affected pregnant women causing microcephaly in their new-borns and also has caused GBS-like manifestations in affected individuals. Currently the outbreak is concentrated in the countries of South American continent, but the omnipresence of its vector has made the world community cautious about the potential of its spread; thus the great emphasis is on prevention and vector control strategies to counter Zika virus attack. Consequently, Ministry of Health, Government of India has also taken cognizance of this and issued guidelines to tackle this problem.

Myasthenia Gravis with Amyotropic Lateral Sclerosis: A Rare Co-existence.

The co-occurrence of myasthenia gravis with motor neurone disease is not a very common association and may pose problem and confusion in the minds of the treating physician because of the gamut of neurological symptoms. This case intends to highlight these dilemmas.

Isolated right ventricular cardiomyopathy with autoimmune hypothyroidism: a rare association in an adolescent.

A 13-year-old girl presented with progressive dyspnoea and palpitation, diagnosed on echocardiography as primary right ventricular cardiomyopathy with atrial fibrillation. Her thyroid profile was positive for antithyroid microsomal antibody, and antithyroid peroxidase antibodies were suggestive of autoimmune hypothyroidism. She was managed with furosemide, digoxin, acenocoumarol and thyroxine following which she showed significant improvement. This is a rare case of isolated right ventricular cardiomyopathy and its association with autoimmune hypothyroidism presenting at the age of 13.

Ebola Virus: Another Challenge from the Deadly Viral Brigade.

Ebola viruses are the causative agents of a severe form of viral haemorrhagic fever in man, designated Ebola haemorrhagic fever, and are endemic in regions of central Africa. The recent west African outbreak of Ebolavirus has brought this filoviral infection again in limelight, Indian government has issued guidelines to various airports to screen travelers coming from Africa and middle east Haj pilgrims to keep a check on this highly virulent infection. This viral hemorrhagic disease has remained confined majorly to Africa but its high outbreak potential makes it essential for all infectious disease clinicians and people dealing with travel medicine to be cautious. Management of these patients with symptomatic therapy is the current strategy which is followed. There is absence of any effective vaccine so further research is warranted in this direction.

Prevention of perinatal HIV I transmission by protease inhibitor based triple drug antiretroviral therapy versus nevirapine as single dose at the time of delivery.

In India, parent to child transmission is the most important source of HIV infection in children below fifteen years of age. Transmission of HIV from mother to child can occur even at low or undetectable HIV virus levels. CD4 count or HIV RNA levels should not be the determining factor when deciding whether to use antiretroviral drugs for prevention of perinatal transmission of HIV. Use of single dose nevirapine during labour, in prevention of parent to child transmission (PPTCT) programme for pregnant females with CD4 count > 250 cells/cumm has less efficacy in reducing perinatal transmission. And there are high chances of development of nevirapine resistance to both mother and baby after single dose nevirapine exposure. Short course Protease inhibitor(PI) based triple drug combination ART from 28 weeks till delivery for perinatal prophylaxis is effective in reducing perinatal HIV transmission. PI's are safe in pregnancy and also have less chances of development of resistance when used for perinatal prophylaxis and stopped post delivery.Hence, it is opined that PI based combination ART should be offered to pregnant females in PPTCT programme, thereby preventing occurrence of paediatric HIV infection in India. This can have significant impact on the society at large.

Crimean Congo hemorrhagic fever: requires vigilance and not panic.

Crimean Congo hemorrhagic fever (CCHF) has been in the news with reports of its outbreak in India from Gujarat. CCHF is caused by a virus which is a member of the Nairovirus genus of the family Bunyaviridae. All of these viruses are transmitted by either ixodid or argasid ticks. Humans get this infection after a bite of an infected tick or from one infected human to another by contact with infectious blood or body fluids. Workers in livestock and agriculture industry, slaughterhouses, and veterinary practice are most prone to this infection. In severe cases after 3-6 days of the onset of symptoms hemorrhagic manifestations occur. IgG and IgM antibodies may be detected in serum by ELISA from about the sixth day of the illness. The mainstay of treatment in CCHF is supportive. Management of DIC, sepsis, shock and MODS should be undertaken. The antiviral drug Ribavirin has shown benefits. Benefits of treatment with ribavirin outweigh the fatal risks, and ribavirin may therefore be recommended. People at risk should use effective personal protective measures against tick bites. Acaricide treatment of livestock in CCHF virus endemic areas is effective in reducing the population of infected ticks.

Oral manifestations of HIV.

The infection of the root canal system is considered to be a polymicrobial infection, consisting of both aerobic and anaerobic bacteria. Because of the complexity of the root canal infection, it is unlikely that any single antibiotic could result in effective sterilization of the canal. A combination of antibiotic drugs (metronidazole, ciprofloxacin, and minocycline) is used to eliminate target bacteria, which are possible sources of endodontic lesions. Three case reports describe the nonsurgical endodontic treatment of teeth with large periradicular lesions. A triple antibiotic paste was used for 3 months. After 3 months, teeth were asymptomatic and were obturated. The follow-up radiograph of all the three cases showed progressive healing of periradicular lesions. The results of these cases show that when most commonly used medicaments fail in eliminating the symptoms then a triple antibiotic paste can be used clinically in the treatment of teeth with large periradicular lesions.