A rare cause of lymphadenopathy - Rosai-Dorfman disease in a HIV-positive Ugandan woman.

This case illustrates a rare cause of lymphadenopathy as a presenting feature of HIV and highlights the importance HIV testing in all patients who present with lymphadenopathy.

Adding rituximab to CODOX-M/IVAC chemotherapy in the treatment of HIV-associated Burkitt lymphoma is safe when used with concurrent combination antiretroviral therapy.

OBJECTIVES: CODOX-M/IVAC (cyclophosphamide, vincristine, doxorubicin-methatrexate/ifusamide, etoposide, cytarabine) chemotherapy is commonly used to treat Burkitt lymphoma and in the HIV-negative population. Rituximab is often added with suggested survival benefits. Concerns over increased toxicity in an already immunocompromized population have prevented its routine addition in people living with HIV (PLWH). This study evaluated the effect on treatment-related toxicity and efficacy of adding rituximab to CODOX-M/IVAC chemotherapy in PLWH. DESIGN: Retrospective review of 91 PLWH (74 men) with Burkitt lymphoma treated in five London centers between 2003 and 2013. All patients received combination antiretroviral therapy. RESULTS: Forty-nine patients received CODOX-M/IVAC and 42 rituximab (R)-CODOX-M/R-IVAC. The addition of rituximab did not confer any significant increase in grade 3/4 toxicities including infections, mucositis, diarrhea, renal impairment, and tumor lysis syndrome. There was no significant difference in toxic deaths between groups (P = 0.14). The 2-year overall survival (OS) was greater for patients receiving rituximab {2-year OS 72% [95% confidence interval (CI) 0.22-0.92, hazard ratio 0.46] vs. 55% [95% CI 1.1-4.5, hazard ratio 2.2]; log-rank P = 0.04}. Similarly, the 2-year progression-free survival (PFS) was greater in the rituximab cohort [2-year PFS 81% (95% CI 0.21-0.99, hazard ratio 0.46) vs. 55% (95% CI 1.0-4.8, hazard ratio 2.2); log-rank P = 0.04]. CONCLUSION: Our multicenter analysis is the largest to date in this population and showed that the addition of rituximab to CODOX-M/IVAC chemotherapy confers no increase in toxicity and results in significantly improved OS and PFS in PLWH with Burkitt lymphoma who receive concomitant combination antiretroviral therapy.

HIV status does not impair the outcome of patients diagnosed with diffuse large B-cell lymphoma treated with R-CHOP in the cART era.

OBJECTIVE: To compare the outcome of patients diagnosed with HIV infection and diffuse large B-cell lymphoma (DLBCL) treated with R-CHOP in the cART era with that of a HIV-negative control group. METHODS: From 2003 to 2011, 305 patients (97 HIV-positive) were diagnosed with DLBCL and treated with R-CHOP. Clinical features were compared using chi-square or Fisher's exact test. Survival analysis was performed using the Kaplan-Meier method and log-rank test. Multivariate analysis was performed using the Cox regression proportional hazards model. RESULTS: HIV-positive patients had more B symptoms and extranodal sites of disease at diagnosis, but the proportion of patients with high-intermediate/high-risk disease according to the international prognostic index (IPI) was similar between groups. Response rate was 73%, both for patients with and without HIV infection. After a median follow-up of 48 months, 30 patients relapsed after achieving a complete remission, including four HIV-positive patients. Ninety-six patients have died (19 HIV-positive), 73 of them due to DLBCL. Three patients (one HIV-positive) died due to treatment toxicity. Patients with HIV infection had a significantly longer disease-free survival (DFS) (5-year: 94 vs. 77%; P = 0.03) and overall survival (OS) (78 and 64% for HIV-positive and HIV-negative patients, respectively; P = 0.03). These results were confirmed on multivariate analysis when controlled for other potential prognostic confounders. CONCLUSION: HIV-positive patients diagnosed with DLBCL in the cART era have an excellent outcome when treated with standard immunochemotherapy. Therefore, the choice of chemotherapy in patients with lymphoma should not be influenced by HIV status.

A retrospective, multi-center analysis of treatment intensification for human immunodeficiency virus-positive patients with high-risk diffuse large B-cell lymphoma.

This analysis reviews the response rate (RR), treatment toxicity and overall survival (OS) for human immunodeficiency virus (HIV)-positive patients with high-risk diffuse large B-cell lymphoma (DLBCL) and the impact of treatment intensification. Fifty patients, treated with either rituximab, cyclophosphamide, doxorubicin, vincristine and prednisolone (R-CHOP) (n = 35) or cyclophosphamide, vincristine, doxorubicin, methotrexate/etoposide, ifosfamide, cytarabine (CODOX-M/IVAC) ± R (n = 15) chemotherapy, were included. Baseline characteristics did not differ between the two treatment groups. Forty-seven patients (94%) received rituximab and 48 (96%) received combination anti-retroviral therapy, with chemotherapy. The RR and treatment-related mortality were not significantly different between the two groups. Overall, 68% achieved complete remission. There were significantly more infections and non-hematological toxicities in the CODOX-M/IVAC ± R group. With a median follow-up of 28 months, 2-year progression-free survival (PFS) and OS are 68% and 70%, respectively, with no significant differences in remission duration, PFS or OS between the groups. In our cohort, the outcome for HIV-positive patients with high-risk DLBCL is favorable. Treatment intensification is feasible, but demonstrated no advantage over R-CHOP.

HIV status does not influence outcome in patients with classical Hodgkin lymphoma treated with chemotherapy using doxorubicin, bleomycin, vinblastine, and dacarbazine in the highly active antiretroviral therapy era.

PURPOSE: The prognosis of HIV-infected patients with non-Hodgkin lymphoma in the highly active antiretroviral therapy (HAART) era approaches that of the general population when they are treated with the same protocols. We analyzed the outcome of patients with Hodgkin lymphoma (HL) treated with doxorubicin, bleomycin, vinblastine, and dacarbazine (ABVD) in the HAART era according to HIV serostatus to establish whether this also holds true for HL. PATIENTS AND METHODS: From 1997 to 2010, 224 patients newly diagnosed with HL, of whom 93 were HIV positive, were consecutively treated with ABVD chemotherapy. HIV-positive patients had more high-risk disease according to the International Prognostic Score (IPS) than HIV-negative patients (IPS≥3: 68% v 26%, respectively; P<.001). Forty-seven HIV-positive patients had a CD4 count less than 200/µL, and 92 patients received HAART during chemotherapy. RESULTS: The complete response rate was 74% for HIV-positive patients and 79% for HIV-negative patients (P=not significant). After a median follow-up of 60 months (range, 8 to 174 months), 23 patients (16 HIV-negative and seven HIV-positive patients) have experienced relapse at a median time of 6 months (range, 1 to 106 months). Five-year event-free survival (EFS) was 59% (95% CI, 47% to 70%) for HIV-positive patients and 66% (95% CI, 57% to 74%) for HIV-negative patients (P=not significant). Five-year overall survival (OS) was 81% (95% CI, 69% to 89%) and 88% (95% CI, 80% to 93%) for HIV-positive and HIV-negative patients, respectively (P=not significant). HIV status did not predict OS or EFS on multivariate analysis including IPS and HIV status. CONCLUSION: This mature study demonstrates that HIV-positive patients with HL have more extensive disease with more adverse prognostic factors than HIV-negative patients, but when treated with ABVD, HIV infection does not adversely affect OS or EFS.

Exploring staff attitudes to routine HIV testing in non-traditional settings: a qualitative study in four healthcare facilities.

OBJECTIVES: To explore staff attitudes towards and experiences of the implementation of routine HIV testing in four healthcare settings in areas of high diagnosed HIV prevalence. METHODS: As part of the HINTS (HIV Testing in Non-traditional Settings) Study, routine offer of an HIV test to all 16-65-year-old patients was conducted for 3 months in an emergency department, an acute admissions unit, a dermatology outpatients department and a primary care practice. The authors conducted focus groups with staff at these sites before and after the implementation of testing. Transcriptions of focus groups were subject to thematic analysis. RESULTS: Four major themes were identified: the stigma of HIV and exceptionalisation of HIV testing as a condition; the use of routine testing compared with a targeted strategy as a means of improving the acceptability of testing; the need for an additional skill set to conduct HIV testing; and the existence within these particular settings of operational barriers to the implementation of HIV testing. Specifically, the time taken to conduct testing and management of results were seen by staff as barriers. There was a clear change in staff perception before and after implementation of testing as staff became aware of the high level of patient acceptability. CONCLUSIONS: The routine offer of HIV testing in general medical services is feasible, but implementation requires training and support for staff, which may be best provided by the local sexual health service.

HIV testing in non-traditional settings--the HINTS study: a multi-centre observational study of feasibility and acceptability.

BACKGROUND: UK guidelines recommend routine HIV testing in healthcare settings if the local diagnosed HIV prevalence >2/1000 persons. This prospective study assessed the feasibility and acceptability, to patients and staff, of routinely offering HIV tests in four settings: Emergency Department, Acute Care Unit, Dermatology Outpatients and Primary Care. Modelling suggested the estimated prevalence of undiagnosed HIV infection in attendees would exceed 1/1000 persons. The prevalence identified prospectively was not a primary outcome. METHODS: Permanent staff completed questionnaires assessing attitudes towards routine HIV testing in their workplace before testing began. Subsequently, over a three-month period, patients aged 16-65 were offered an HIV test by study staff. Demographics, uptake, results, and departmental activity were collected. Subsets of patients completed questionnaires. Analyses were conducted to identify factors associated with test uptake. FINDINGS: Questionnaires were received from 144 staff. 96% supported the expansion of HIV testing, but only 54% stated that they would feel comfortable delivering testing themselves, with 72% identifying a need for training. Of 6194 patients offered a test, 4105 (66·8%) accepted (61·8-75·4% across sites). Eight individuals were diagnosed with HIV (0-10/1000 across sites) and all transferred to care. Younger people, and males, were more likely to accept an HIV test. No significant associations were found between uptake and ethnicity, or clinical site. Questionnaires were returned from 1003 patients. The offer of an HIV test was acceptable to 92%. Of respondents, individuals who had never tested for HIV before were more likely to accept a test, but no association was found between test uptake and sexual orientation. CONCLUSIONS: HIV testing in these settings is acceptable, and operationally feasible. The strategy successfully identified, and transferred to care, HIV-positive individuals. However, if HIV testing is to be included as a routine part of patients' care, additional staff training and infrastructural resources will be required.

'You can't tell by looking': pilot study of a community-based intervention to detect asymptomatic sexually transmitted infections.

Innovative and non-stigmatizing interventions are required to reduce ethnic inequalities in rates of sexually transmitted infections among young people. We therefore designed an intervention, 'You can't tell by looking,' which combined health promotion with testing for gonorrhoea and chlamydia using nucleic acid amplification technology and treatment and partner notification delivered in the non-clinical settings. One hundred and eighty-one participants were seen in 13 sessions in local further education colleges. Forty-three percent of participants were from Black Caribbean or Black Other ethnic groups and 39% were Black African: 125 of 181 participants were sexually active and 109 of these (87%) provided a urine specimen. 10/109 (9.2%, 95% confidence interval 4.5-16.2%) samples were confirmed positive for Chlamydia trachomatis and two were also positive for Neisseria gonorrhoeae. Only 7% of those tested found it embarrassing. The intervention was both feasible and acceptable to young people. It could be tested in a wider variety of non-clinical settings and evaluated in a cluster randomized trial.

Co-infection with gonorrhoea and chlamydia: how much is there and what does it mean?

A cross-sectional study of new clients with either gonorrhoea or chlamydia attending King's College Hospital in 1998. One thousand two hundred and thirty-nine women and 1141 men had gonorrhoea, chlamydia or both. Overall, 24.2% (124/512) of heterosexual men and 38.5% (136/353) of women with gonorrhoea also had chlamydia (P<0.001). Of heterosexual males 18.8% (124/660) and 13% (136/1022) of females with chlamydia also had gonorrhoea (P=0.002). Ethnicity had no effect on the proportion of co-infection after controlling for age and gender. Clients with dual infection were younger than those with either infection alone (P=0.0001). Over half of women and a quarter of men aged 15 to 19 years were dually infected so testing for both gonorrhoea and chlamydia may be appropriate in this age group in settings outside genitourinary clinics. The high proportion of cases of gonorrhoea that also have chlamydia justifies the policy of epidemiological treatment for chlamydia.