EID Journal: XDR-TB/HIV Treatment Outcomes

(From the 2011 TB Progress Report)

 

# 6828

 

 

Despite great advances made against tuberculosis since the introduction of antibiotics in the 1940s, in recent years we’ve seen the rise of new drug resistant strains of this killer disease; MDR-TB (Multi-drug Resistant Tuberculosis) and XDR-TB (Extensively Drug Resistant Tuberculosis).

 

Although the numbers have decreased in recent years, in 2010 1.4 million deaths were attributed TB, and it remains one of the three greatest causes of death of women (ages 14-44) in the world.

 

In 2009, the NIH had this to say about the global spread of the disease, including the fact that about 1 in 5 active cases of TB are also co-infected with HIV.

 

Today, one-third of the world’s population is thought to be infected with Mycobacterium tuberculosis (Mtb), the microbe that causes TB.

 

An estimated 13.7 million people have the active form of the disease. In 2007, approximately 9.27 million people developed TB, of whom 1.37 million were HIV positive, and 1.75 million died, including 456,000 individuals co-infected with HIV.

 

And in 2010, the World Health Organization announced:

 

Drug-resistant tuberculosis now at record levels

18 MARCH 2010 | GENEVA | WASHINGTON DC -- In some areas of the world, one in four people with tuberculosis (TB) becomes ill with a form of the disease that can no longer be treated with standard drugs regimens, a World Health Organization (WHO) report says.

 

Also from the World Health Organization:

 

Tuberculosis and HIV

 

The risk of developing tuberculosis (TB) is estimated to be between 20-37 times greater in people living with HIV than among those without HIV infection. In 2010, there were 8.8 million new cases of TB, of which 1.1 million were among people living with HIV.

In response to demands from countries, WHO recommends 12 TB/HIV collaborative activities, including the Three I's for HIV/TB. The WHO HIV/AIDS and TB Departments and their partners, including community groups, work collaboratively on joint HIV/TB advocacy, policy development and implementation in countries.

The Three I’s

• Intensified TB case finding
• Isoniazid preventive therapy
• Infection control for TB.

 

While the incidence of co-infection with XDR-TB and HIV is rising, little is known about the effectiveness of treatment of these patients.

 

We’ve some new research, appearing in the CDC’s EID Journal, indicating that among a small cohort of patients followed in South Africa over 2 years – disappointingly - only 22% were cured or successfully completed treatment.

 

A few excerpts ( reparagraphed for readability), but follow the link to read the entire study:

 

 

Treatment Outcomes for Extensively Drug-Resistant Tuberculosis and HIV Co-infection

Max R. O’Donnell , Nesri Padayatchi, Charlotte Kvasnovsky, Lise Werner, Iqbal Master, and C. Robert Horsburgh

Abstract

High mortality rates have been reported for patients co-infected with extensively drug-resistant tuberculosis (XDR-TB) and HIV, but treatment outcomes have not been reported. We report treatment outcomes for adult XDR TB patients in KwaZulu-Natal Province, South Africa. Initial data were obtained retrospectively, and outcomes were obtained prospectively during 24 months of treatment.

 

A total of 114 XDR TB patients were treated (median 6 drugs, range 3–9 drugs); 82 (73%) were HIV positive and 50 (61%) were receiving antiretroviral therapy. After receiving treatment for 24 months, 48 (42%) of 114 patients died, 25 (22%) were cured or successfully completed treatment, 19 (17%) withdrew from the study, and 22 (19%) showed treatment failure.

 

A higher number of deaths occurred among HIV-positive patients not receiving antiretroviral therapy and among patients who did not show sputum culture conversion. Culture conversion was a major predictor of survival but was poorly predictive (51%) of successful treatment outcome.

 

Discussion

The main findings of our study were a high mortality rate (42%) and a low rate of successful treatment outcomes (22%) for XDR TB patients after completion of 24 months of treatment in a setting with a high incidence of HIV.

 

All deaths in this cohort occurred in the first 12 months after start of treatment. Predictors of deaths in this cohort included TB-specific (TB culture conversion) and HIV-specific (ART use) factors. Consistent with findings in other studies of treatment of drug-resistant TB/HIV, HIV was not independently associated with death (12,13,20).

 

Although HIV was not independently associated with death, use of ART among HIV-infected patients was associated with improved survival.

 

Sex appeared to modify the association between death and HIV because female sex was associated with higher survival rates among HIV-negative XDR TB patients but with higher death rates in women co-infected with HIV than in men co-infected with HIV.

 

However, this finding was not significant in all strata. TB culture conversion was a useful predictor of survival and treatment outcome. However, it was not sufficiently sensitive in this cohort to be a surrogate for successful TB treatment outcome, given the number of patients who ultimately showed treatment failure (n = 7), defaulted (n = 7), or died (n = 4) after TB culture conversion.

 

 

The authors conclude by saying:

 

Although not addressed by our study, improvements in treatment outcomes for patients co-infected with MDR TB and HIV will require changes in HIV- and TB-related factors. For HIV, these include more rapid HIV testing for early initiation of ART, appropriate monitoring of CD4 T-cell counts, HIV virus load testing, appropriate opportunistic infection prophylaxis, and improvement in ART adherence.

 

Although not addressed by our study, we recommend that for TB these improvements include widespread implementation of rapid diagnostics, particularly for smear-negative disease; early drug susceptibility testing for first-line and second line agents; improvement in adherence for second-line TB drugs; development of more effective anti-TB drugs and regimens; and guidance of drug selection by timely and ongoing drug susceptibility testing.

 

 

While often overshadowed by other issues, the HIV AIDS epidemic (exacerbated by TB) in South Africa (and much of Sub-Saharan Africa) continues to devastate the populace.

 

The UNAIDS website lists the following grim statistics for South Africa, a country that has seen more than a 10 year-drop in life expectancy since HIV began to spread in the 1980s:

 

HIV AND AIDS ESTIMATES (2011)

Number of people living with HIV

5,600,000 [5,300,000 - 5,900,000]

 

Adults aged 15 to 49 prevalence rate

17.30% [16.60% - 18.10%]

 

Adults aged 15 and up living with HIV

5,100,000 [4,900,000 - 5,400,000]

 

Women aged 15 and up living with HIV

2,900,000 [2,700,000 - 3,000,000]

 

Children aged 0 to 14 living with HIV

460,000 [410,000 - 520,000]

 

Deaths due to AIDS

270,000 [240,000 - 300,000]

 

Orphans due to AIDS aged 0 to 17

2,100,000 [2,000,000 - 2,300,000]

»» Read More

World AIDS Day 2012

# 6756

 

 

While we remain vigilant against the next pandemic – likely to arise from a zoonotic source – the world continues to battle the HIV virus, which has taken the lives of roughly 30 million people over the past 3 decades.

 

Today, December 1st, is World AIDS Day which serves to draw attention to the current status of this global epidemic.  The theme of this year’s observance is `Working Together for an AIDS-Free Generation’.

 

Thirty years into this epidemic, it would be hard to find anyone whose life hasn’t been touched in some way by this disease.   According to this week’s MMWR:

 

In the United States, approximately 602,000 persons diagnosed with AIDS have died since the first cases were reported (3), and approximately 50,000 persons become infected with HIV each year (4). An estimated 1.1 million persons in the United States are living with HIV infection (5).

 

The United States government maintains an extensive AIDS/HIV information website, called AIDS.gov.  Here you’ll find suggestions as to how you can help today, and every day, with the fight against  AIDS and HIV.

 

 

Below you’ll find a short video produced by AIDS.Gov on World AIDS Day 2012.

 

 

For a more international perspective you may wish to visit http://www.worldaidscampaign.org/

 

 

 

WORLD AIDS DAY

World AIDS Day is celebrated on December 1 each year around the world. It has become one of the most recognised international health days and a key opportunity to raise awareness, commemorate those who have passed on, and celebrate victories such as increased access to treatment and prevention services.

 

UNAIDS took the lead on World AIDS Day campaigning from its creation until 2004. From 2004 onwards the World AIDS Campaign’s Global Steering Committee began selecting a theme for World AIDS Day in consultation with civil society, organisations and government agencies involved in the AIDS response.

 

Themes run for one or two years and are not just specific to World AIDS Day. Campaigning slogans such as ‘Stop AIDS. Keep the Promise’ have been used year round to hold governments accountable for their HIV and AIDS related commitments.

 

History of World Aids Day
World AIDS Day Timeline : 1988 – 2011

World Aids Day Publications
Publications and reports on human rights and universal access

»» Read More

NYC: The Other Meningitis Outbreak

 

# 6628

 

While the media is understandably focused on the growing fungal meningitis outbreak linked to potentially contaminated steroid injections (see CDC Update: Multi State Meningitis Outbreak – Oct 11th), another outbreak of bacterial meningitis has been reported in New York City over the past several weeks among HIV positive men.

 

The following notice comes from the New York City Department of Health and Mental Hygiene.

Health Department Recommends Vaccination for HIV-Positive Men at High Risk of Meningitis

The Health Department issued recommendations today for vaccinating against invasive meningococcal disease – commonly known as meningitis – after a spike of cases reported over the past five weeks.

 

The Department is advising vaccinations for any man who is HIV positive and has had intimate contact with another man that he met through a website, digital application (“App”), or at a bar or party since September 1, 2012.

 

Vaccines will be available starting Friday at medical facilities throughout the city for men who meet these criteria but who cannot obtain it from their HIV care providers.

 
Read the Press Release

Find a Nearby Clinic with the Meningitis Vaccine

Read the Fact Sheet on the Outbreak

Learn More About Invasive Meningococcal Disease

See Information for Healthcare Providers

 

From the Fact Sheet on this outbreak:

 

Meningococcal Outbreak Patient Fact Sheet

 

An outbreak of invasive meningococcal disease has recently been identified among HIV-infected men who have sex with men. The New York City Department of Health and Mental Hygiene recommends meningococcal vaccination for the following persons: 

Men who are HIV-infected and who have had intimate contact with another man met through a website, digital application (“app”), or at a bar or party since September 1, 2012.

 

If you think you may be at risk, please read the answers to some important questions below.

What is invasive meningococcal disease?

Invasive meningococcal disease is a serious infection that can cause a high fever, headache, stiff neck, and rash. Some people die from the infection. If you develop these symptoms, you should immediately seek medical care.

 
Does having HIV put me at greater risk of invasive meningococcal disease?

People living with HIV are at greater risk than the general population of acquiring the infection
that causes invasive meningococcal disease. Approximately 20% of people who develop the
disease die of it. 

How is invasive meningococcal disease spread?

The disease is spread by prolonged close contact with an infected person. Examples of prolonged close contact include kissing and having sex. In addition, sharing eating utensils, a drinking glass, or a cigarette with an infected person may spread the disease. It is NOT spread by simply breathing the air where a person with the disease has been.

How can I protect myself?

There are several vaccines licensed for use in adults that can help protect people against invasive meningococcal disease. Meningococcal vaccine may provide protection 7 to 10 days after vaccination, but not everyone will develop protective levels of antibodies. If you are HIV-infected and you do receive the meningococcal conjugate vaccine, you should return to your health care provider eight weeks later for a second dose. 

If you are HIV-infected and need a health care provider, call 311 to find one.

If you do not know your current HIV status, get tested. NYC residents can receive a free HIV test at one of the Health Department’s Sexually Transmitted Disease (STD) or Tuberculosis (TB) clinics, regardless of insurance or immigration status. Call 311 to find a location near you.

Should I get vaccinated with the meningococcal vaccine?

 
If you meet all the criteria listed above, then the Health Department recommends that you receive
meningococcal vaccine.

 

 

For more, we go to the CDC’s Bacterial Meningitis Information page:

 

Bacterial Meningitis

Bacterial meningitis is usually severe. While most people with meningitis recover, it can cause serious complications, such as brain damage, hearing loss, or learning disabilities.

 

There are several pathogens (types of germs) that can cause bacterial meningitis. Some of the leading causes of bacterial meningitis in the United States include Haemophilus influenzae (most often caused by type b, Hib), Streptococcus pneumoniae, group B Streptococcus, Listeria monocytogenes, and Neisseria meningitidis.

 

In the United States, about 4,100 cases of bacterial meningitis, including 500 deaths, occurred each year between 2003–2007.

 

Signs & Symptoms

Meningitis infection may show up in a person by a sudden onset of fever, headache, and stiff neck. It will often have other symptoms, such as

• Nausea
• Vomiting
• Increased sensitivity to light (photophobia)
• Altered mental status (confusion)

The symptoms of bacterial meningitis can appear quickly or over several days. Typically they develop within 3-7 days after exposure.

 

(Continue . . . )

 

»» Read More

Study: Intra-Continental Spread of Invasive Non-Typhoidal Salmonella

 

 Salmonella typhimurium bacteria – Credit CDC PHIL

 

 

# 6599

 

You might not think there’d be much of a connection between an emergent serotype of Salmonella and the HIV epidemic in Sub-Saharan Africa - but if researchers from the Wellcome Trust Sanger Institute have it right - this highly pathogenic bacterial strain may have had a powerful viral ally.

 

There are more than 2500 serovars of Non-Typhoidal Salmonella (NTS) that can produce gastroenteritis or other infections in humans. Taken together, these Gram negative, anaerobic bacteria are believed to be the second most common source of food poisoning in the United States.

 

Those infected often develop diarrhea, fever, vomiting, and abdominal cramps that may persist for several days.

 

In the western world most recover without treatment, although the CDC estimates that nearly 400 people infected die each year in the United States (Cite  CDC Food borne Illness Estimates).

 

In developing countries, Non-typhoidal Salmonella can (and does) exact a much higher toll, particularly among those who may be malnourished or suffer from chronic ailments such as malaria and HIV.

 

In recent years researchers have also noted a much more virulent form of NTS, spreading across sub-Saharan Africa, that they’ve dubbed  Invasive Non-Typhoidal Salmonella (iNTS). 

 

Not only is it a multi-drug resistant strain, it is fatal in about 25% of those who contract it.

 

Today, we’ve a study that appears in Nature Genetics that links the Intracontinental spread and evolution of this invasive and severe form of Salmonella to the emergence and spread of HIV.

 

Intracontinental spread of human invasive Salmonella Typhimurium pathovariants in sub-Saharan Africa

Chinyere K Okoro,Robert A Kingsley,Thomas R Connor,Simon R Harris,Christopher M Parry,Manar N Al-Mashhadani,Samuel Kariuki,Chisomo L Msefula,Melita A Gordon,Elizabeth de Pinna,John Wain,Robert S Heyderman,Stephen Obaro,Pedro L Alonso,Inacio Mandomando,Calman A MacLennan, Milagritos D Tapia,Myron M Levine,Sharon M Tennant,Julian Parkhill & Gordon Dougan

Published online 30 September 2012

 

While the bulk of the study is behind a pay wall, the Abstract is available, as is this press release from the Wellcome Trust Sanger Institute.

 

New pathogen epidemic identified in sub-Saharan Africa

Researchers track the spread of human invasive non-Typhoidal Salmonella in sub-Saharan Africa

A new study out today (Sunday 30 September) reveals that the emergence and spread of a rapidly evolving invasive intestinal disease, that has a significant mortality rate (up to 45%) in infected people in sub-Saharan Africa, seems to have been potentiated by the HIV epidemic in Africa.

 

The team found that invasive non-Typhoidal Salmonella (iNTS) disease is caused by a new form of the bacteria Salmonella Typhimurium that has spread from two different focal hubs in Southern and Central Africa beginning 52 and 35 years ago, respectively. They also found that one of the major contributing factors for the successful spread of iNTS was the acquisition of genes that afford resistance to several front line drugs used to treat blood-borne infection such as iNTS.

 

iNTS is a blood-borne infection that kills approximately one of four people in sub-Saharan Africa who catch it. Yet, in the rest of the world, NTS is a leading cause of acute inflammatory diarrhoea that is self-limiting and tends to be fatal in less than 1 per cent of people infected. The disease is more severe in sub-Saharan Africa than the rest of the world because of factors such as malnutrition, co-infection with malaria or HIV and potentially the novel genotype of the Salmonella bacteria.

 

"The immune system susceptibility provided by HIV, malaria and malnutrition at a young age, may provide a population in sub-Saharan Africa that is large enough for this detrimental pathogen to enter, adapt, circulate and thrive," says Chinyere Okoro, joint first author from the Wellcome Trust Sanger Institute. "We used whole genome sequencing to define a novel lineage of Salmonella Typhimurium that is causing a previously unrecognised epidemic across the region. Its genetic makeup is evolving into a more typhoid like bacteria, able to efficiently spread around the human body"

 

<SNIP>

 

"There has been some evidence that this disease can be passed from human to human. Now the race is on to discover how NTS is actually transmitted in sub-Saharan Africa so that effective intervention strategies can be implemented."

 

(Continue . . . )

 

 

And for more on all of this, here’s Debra McKenzie’s article for New Scientist.

 

 

HIV could be turning salmonella nastier

 

18:00 30 September 2012 by Debora MacKenzie

 

A nastier kind of salmonella infection has emerged alongside the HIV epidemic in Africa. The finding is the first evidence that HIV might be allowing new human pathogens to evolve in immunosuppressed people.

 

(Continue . . . )

 

»» Read More

December 1st: World AIDS Day

 

 

 

# 5986

 

Like so many others, I’ve lost friends to the AIDS pandemic over the years, which has claimed more than 25 million lives over the past 3 decades. Today there are an estimated 33 million people around the world living with HIV.

 

The availability of antiretroviral therapy (ART) today means that HIV infection isn’t the automatic death sentence it once was, but not everyone is able to get this vital treatment.

 

The global economic difficulties of the past several years have put a dent in public and private funding of many health initiatives, including HIV prevention and treatment (see BBC report  HIV funding cut as science brings 'decisive moment')

 

Progress has been made, however, although not evenly around the world. Today, a brief roundup of World AIDS Day related links.

 

First, from the World Health Organization.

 

Significant global progress in preventing and treating HIV

WHO

30 November 2011 -- The new Report on the global HIV/AIDS response released today, shows inspiring progress with a 15% reduction of new infections and a 22% decline in deaths. This progress highlights the importance of long-term investment in HIV/AIDS. There is now a very real possibility of getting ahead of the epidemic. However, gains made to date are being threatened by a decline in resources for AIDS.

• Read the news release
• Read the new fact sheet on HIV/AIDS

 

 

The ECDC’s report on AIDS and HIV shows that progress isn’t universal, with new HIV infection rates continuing to rise across the European Union and the European Economic Area (EU/EEA).

 

World AIDS Day: HIV transmission shows no sign of declining in Europe

30 Nov 2011

ECDC

Marking World AIDS Day 2011, ECDC and the WHO Regional Office for Europe release today their joint publication HIV/AIDS surveillance in Europe 2010. The new data raises concern about the continuing transmission of HIV in Europe, as newly diagnosed HIV infections are still on the increase.

 

In 2010, 27.116 newly diagnosed HIV infections were reported across the European Union and the European Economic Area (EU/EEA) indicating an increase of around 4%. In contrast, the steady decrease of AIDS cases continued in 2010 with 4.666 reported cases in the EU/EEA region. This constitutes a decrease of nearly 50% in reported AIDS cases from 2004 to 2010.

 

The HIV epidemics are remarkably distinct in individual countries but overall HIV continues to disproportionally affect certain key populations, in particular men who have sex with men, persons originating from countries with generalised HIV epidemics and people who inject drugs.

(Continue . . . )

 

 

 

The CDC’s  MMWR yesterday released a Vital Signs Report:

 

Vital Signs: HIV Prevention Through Care and Treatment — United States

Early Release

November 29, 2011 / 60(Early Release);1-6

Abstract

Background: An estimated 1.2 million persons in the United States were living with human immunodeficiency virus (HIV) infection in 2008. Improving survival of persons with HIV and reducing transmission involve a continuum of services that includes diagnosis (HIV testing), linkage to and retention in HIV medical care, and ongoing HIV prevention interventions, including appropriately timed antiretroviral therapy (ART).

 

Methods: CDC used three surveillance datasets to estimate recent HIV testing and HIV prevalence among U.S. adults by state, and the percentages of HIV-infected adults receiving HIV care for whom ART was prescribed, who achieved viral suppression, and who received prevention counseling from health-care providers. Published data were used to estimate the numbers of persons in the United States living with and diagnosed with HIV and, based on viral load and CD4 laboratory reports, linked to and retained in HIV care.

 

Results: In 2010, 9.6% of adults had been tested for HIV during the preceding 12 months (range by state: 4.9%--29.8%). Of the estimated 942,000 persons with HIV who were aware of their infection, approximately 77% were linked to care, and 51% remained in care. Among HIV-infected adults in care, 45% received prevention counseling, and 89% were prescribed ART, of whom 77% had viral suppression. Thus, an estimated 28% of all HIV-infected persons in the United States have a suppressed viral load.

 

Conclusions: Prevalence of HIV testing and linkage to care are high but warrant continued effort. Increasing the percentages of HIV-infected persons who remain in HIV care, achieve viral suppression, and receive prevention counseling requires additional effort.

 

Implications for Public Health Practice: Public health officials and HIV care providers should improve engagement at each step in the continuum of HIV care and monitor progress in every community using laboratory reports of viral load and CD4 test results.

 

(Continue . . . )

 

 

And last stop is the WORLD AIDS DAY website, where you can find out more about this ongoing pandemic, and how you can help.

 

 

»» Read More

Referral: McKenna On 30 Years Of AIDS

 

 

 

# 5597

 

 

 

This month marks the 30th anniversary of the first detection of what would turn out to be a new devastating global epidemic called HIV-AIDS.

 

The CDC, along with the WHO, and other agencies and entities are commemorating this anniversary in a variety of ways. The CDC’s Division of HIV/AIDS Prevention (DHAP) has set up the following website with blogs, videos, photos and events.

 

 

And you’ll find that this week’s MMWR focuses on HIV Surveillance — United States, 1981–2008 (June 3, 2011 / Vol. 60 / No. 21).

But for a unique look back at the early days of the HIV epidemic, I would direct you to Flublogia’s favorite `scary disease girl’ – Maryn McKenna – who worked for many years for the Atlanta-Journal Constitution as their science, medical and  CDC reporter.

 

In 2004 Maryn published her first book, Beating Back The Devil, which chronicled the history of the CDC’s  Epidemic Intelligence Service. 

 

 

Part of that history, which covered the eradication of smallpox, the near-eradication of polio, and the discovery of Legionnaires' disease (among many others) - was the detection of HIV-AIDS in 1981.

 

Maryn is excerpting portions of her book in her blog this week, and as with just about everything she writes, this is highly recommended.

 

 

30 Years of AIDS, And How It Began. (Part 1)

By Maryn McKenna June 2, 2011

»» Read More

Haiti: Inextricably Intertwined Disasters

 

 

 

# 5078

 

 

 

Long before cholera broke out in the tent cities, and decades prior to the devastating 7.0 Port-au-Prince earthquake, Haiti endured some of the highest rates of poverty and disease in the western hemisphere.

 

A little more than a week ago, in Haiti: Three Non-Cholera Health Threats, I wrote about the toll that Malaria, Cyptosporidium, and Acute Respiratory Infections took on that population.

 

Today, from IRIN PlusNews (hat tip Sharon Sanders at FluTrackers), we have a couple of feature articles on TB and HIV, and how they – along with the earthquake and the cholera epidemic - are inextricably intertwined in the cascading crisis in Haiti.

 

First a report on the additional threat that cholera places on the 2.2% of Haiti’s population (roughly 120,000 people) who have HIV. 

 

HAITI: HIV-positive people especially vulnerable to cholera

PORT-AU-PRINCE, 22 November 2010 (PlusNews) - As the death toll from the cholera epidemic sweeping through Haiti surpasses 1,000, with more than 19,000 confirmed cases, health officials say people living with HIV are especially vulnerable.

 

Only about 25 percent of people infected with cholera develop symptoms - mainly watery diarrhoea and vomiting - but people already weakened by illness, malnutrition or pregnancy are particularly at risk.

 

"[People living with HIV] are very much at risk because they already have a weakened immune system," explained Hanz Legagneur, director of the Ministry of Public Health in the country's West Department.

 

(Continue . . .)

 

 

Next a report on how the living conditions in the 1,300 refugee camps for the survivors of the earthquake – many of whom are crowded into communal tents - are ripe for the spread of Tuberculosis.

 

 

HAITI: Combating TB in Port-au-Prince's tent cities

Photo: Tamar Dressler/IRIN

Thousands are still living in tiny tents in the capital, Port-au-Prince

 

PORT-AU-PRINCE, 17 November 2010 (PlusNews) - Health workers in Haiti are concerned about the spread of tuberculosis (TB) in the tent cities that have housed more than one million people since the massive earthquake in January.

 

"With the quake this became an emergency," said Macarthur Charles, a doctor with Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), one of the largest HIV- and TB-focused NGOs in Haiti.

(Continue . . .)

 

 

Although accurate numbers are impossible to obtain, field reports (well covered on a daily basis by Crofsblog) seem to suggest a higher than expected fatality rate among cholera patients in this epidemic.

 

Not so surprising given the existing burden of disease in Haiti, long-standing fragmentary health care services, poverty and neglect, and the devastation from January’s earthquake.

 

Disasters all. 

 

And all no doubt factors that conspire to severely compound the effects of this cholera epidemic.

 

And they also make solutions that much harder to find.

»» Read More

NIH: Antibodies That Work Against HIV

 

 

# 4711

 

 

After the disappointing failure of the STEP trials in 2007, which utilized a weakened adenovirus 5 as a viral vector to carry HIV genes throughout the body, hopes for seeing a vaccine anytime soon to protect against HIV were dashed.

 

Research around the world, however, has continued.

 

Yesterday the NIH announced the discovery of two human antibodies that show great promise in preventing infection of cells by HIV in the laboratory.

They are hopeful that this research could eventually lead to advances in vaccines for HIV along with other diseases.

 

Here is the link to the NIH press release.

 

 

 

NIH-Led Scientists Find Antibodies that Prevent Most HIV Strains from Infecting Human Cells

Discovery to Advance HIV Vaccine Design, Antibody Therapy for Other Diseases

Scientists have discovered two potent human antibodies that can stop more than 90 percent of known global HIV strains from infecting human cells in the laboratory, and have demonstrated how one of these disease-fighting proteins accomplishes this feat. According to the scientists, these antibodies could be used to design improved HIV vaccines, or could be further developed to prevent or treat HIV infection. Moreover, the method used to find these antibodies could be applied to isolate therapeutic antibodies for other infectious diseases as well.

 

“The discovery of these exceptionally broadly neutralizing antibodies to HIV and the structural analysis that explains how they work are exciting advances that will accelerate our efforts to find a preventive HIV vaccine for global use,” says Anthony S. Fauci, M.D., director of the National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health. “In addition, the technique the teams used to find the new antibodies represents a novel strategy that could be applied to vaccine design for many other infectious diseases.”

 

Led by a team from the NIAID Vaccine Research Center (VRC), the scientists found two naturally occurring, powerful antibodies called VRC01 and VRC02 in an HIV-infected individual's blood. They found the antibodies using a novel molecular device they developed that homes in on the specific cells that make antibodies against HIV. The device is an HIV protein that the scientists modified so it would react only with antibodies specific to the site where the virus binds to cells it infects.

 

The scientists found that VRC01 and VRC02 neutralize more HIV strains with greater overall strength than previously known antibodies to the virus.

(Continue . . .)

»» Read More

Case Study: Co-infection With HIV and Bird Flu

 

 

 

# 4643

 

 

Despite the occasional `Eureka!’ moment, most of our scientific knowledge is gained incrementally, and over months or even years of research.   A single case study, such as the one presented below, doesn’t necessarily tell us a whole lot.   

 

But it does provide a puzzle piece.  And once you’ve gathered enough pieces, you can then begin to put the puzzle together.

 

Human H5N1 infections remain rare, with only about 500 recorded over the past dozen or so years.  HIV , while more common, affects less than 1% of the global population (although in some countries, that number is as high as 15%).

 

Accordingly, there have been few opportunities for scientists to observe HIV positive patients with an H5N1 co-infection.  

 

We’ve one such case study out of Vietnam, published today in BMC Infectious Diseases.  A hat tip to Tetano on FluTrackers for this link.

 

 

 

Influenza A H5N1 and HIV co-infection: case reportAnnette Fox, Peter Horby, Nguyen Hong Ha, Le Nguyen Minh Hoa, Nguyen Tien Lam, Cameron Simmons, Jeremy Farrar, Nguyen Van Kinh, Heiman Wertheim

BMC Infectious Diseases 2010, 10:167 (14 June 2010)
[Abstract] [Provisional PDF]

Background

The role of adaptive immunity in severe influenza is poorly understood. The occurrence of influenza A/H5N1 in a patient with HIV provided a rare opportunity to investigate this.

Case presentation

A 30-year-old male was admitted on day 4 of influenza-like-illness with tachycardia, tachypnea, hypoxemia and bilateral pulmonary infiltrates. Influenza A/H5N1 and HIV tests were positive and the patient was treated with Oseltamivir and broad-spectrum antibiotics. Initially his condition improved coinciding with virus clearance by day 6. He clinically deteriorated as of day 10 with fever recrudescence and increasing neutrophil counts and died on day 16. His admission CD4 count was 100/ul and decreased until virus was cleared. CD8 T cells shifted to a CD27+CD28- phenotype. Plasma chemokine and cytokine levels were similar to those found previously in fatal H5N1.

Conclusions

The course of H5N1 infection was not notably different from other cases. Virus was cleared despite profound CD4 T cell depletion and aberrant CD8 T cell activation but this may have increased susceptibility to a fatal secondary infection.

 

 

While the `The course of H5N1 infection was not notably different from other cases’, there were a few surprises along the way.

First, the patient showed some clinical improvement after two days of treatment (including oseltamivir).  Despite his HIV status, he was apparently able to begin clearing the virus by day 6, much as might be expected in a non-immunocompromised patient.

 

But the patient’s condition deteriorated around day 10 with relapse of fever, a raised CRP (C-Reactive Protein) level, and neutrophilia (elevated neutrophil white count) – all suggestive of a secondary infection. 

 

Throughout his hospitalization, however, the patient’s lab cultures were negative for bacterial infection, but positive for Candida albicans (and eventually, on 14) Aspergillus fumigatus.

 

Despite aggressive antibiotic and antifungal treatment, the patient died on day 16 of respiratory and renal failure.   A fate, and course of illness, not unlike that which we’ve seen with a great many other H5N1 cases.

 

It is possible, according to the authors, that the administration of corticosteroids early in this patient’s treatment may have contributed to the development of invasive pulmonary aspergillosis.

 

The authors conclude with the following (but read the whole report):

 

In conclusion  the course of H5N1 infection  in  this case was not notably different  in  the presence of HIV co-infection but  it  is possible  that HIV co-infection and profound CD4 T cell depletion  increase susceptibility  to secondary  infection.

The  findings suggest  that CD4 T cells may not be  required  for H5N1 virus clearance.

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