Search

Objective: To determine the percentage of patients in whom the diagnosis 'HIV infection' was made late, which factors are associated with an increased risk of a late HIV diagnosis, and if there are opportunities for an earlier diagnosis., Design: Retrospective analysis., Method: We included all HIV positive patients who were treated at the Erasmus Medical Center Rotterdam in the period January 1996-March 2012. We divided these patients into two groups: patients with a timely diagnosis and patients with a late diagnosis (CD4+ T cell count < 350/mm3). We performed a structured interview in patients who were diagnosed in the period January 2009-March 2012. To determine possible risk factors for a late diagnosis we used univariate and multivariate analyses., Results: A late diagnosis 'HIV infection' was made in 59% of the 2256 patients. Independent patient characteristics associated with a late diagnosis were heterosexual transmission (odds ratio (OR): 1.87; 95% CI: 1.44-2.43; p < 0.001), age > 50 years (OR: 1.73; 95% CI: 1.28-2.34; p < 0.001), and a Sub-Saharan African (OR: 1.66; 95% CI: 1.02-2.71; p = 0.043) or Asian origin (OR: 2.31; 95% CI: 1.20-4.43; p = 0.012). The interviews showed that more than 75% of patients with a late HIV diagnosis were already known with a risk factor for HIV, according to the STD practice guideline from the Dutch College of General Practitioners., Conclusion: In the past 15 years, 59% of HIV positive patients in Rotterdam presented late. This mainly concerned patients older than 50 years and immigrants originating from HIV endemic areas. It is important to prevent a late diagnosis, as this can lead to poorer response to combination antiretroviral therapy and higher mortality.

Since the HIV epidemic, the incidence ofanorectal (pre)malignancies in men who have sex with men (MSM) is increasing. The incidence is likely to increase further in the coming years, given that HIV-positive MSM are living longer thanks to powerful antiretroviral treatment. Persistent human papillomavirus (HPV) infection is a major risk factor for the development of anal (pre)malignancies. Less is known about the natural history of anal intraepithelial neoplasia (AIN). Screening in HIV-positive and HIV-negative MSM for anorectal malignancies or dysplasia is cost-effective if the incidence is sufficiently high. Treatment options range from watchful waiting for asymptomatic grade-1 AIN to excision or radio(chemo)therapy for anorectal carcinoma. HPV vaccines are in development. Especially in HIV-positive MSM with anorectal complaints or genital warts in their medical history, one should consider these malignancies.

An acute hepatitis C infection was diagnosed in three HIV-positive gay men, aged 43, 48 and 30 years, respectively. In all three, unprotected sexual intercourse and fisting was a universal risk factor for the infection. They all denied having used drugs intravenously, which is the most common risk factor. The third man had a documented proctitis (lymphogranuloma venereum) at the time when the HCV transmission must have taken place. No serious complications occurred during the acute HCV infection. Because the infection did not resolve spontaneously after a few months, all three men were treated with pegylated interferon and ribavirin. Recently, the number of cases of acute HCV infection has been seen to increase in The Netherlands. This may be due primarily to an increase in unprotected sexual intercourse and fisting. This hypothesis is supported by a documented increased prevalence of sexually transmissible diseases among gay men in The Netherlands. As acute infections may turn into chronic infections, treatment of an acute infection should be considered in order to prevent the chronic disease.

Objective: To assess the side effects, safety and efficacy of highly active antiretroviral therapy (HAART) in a cohort of HIV-infected pregnant women in the Netherlands., Design: Retrospective., Method: Data were collected from the medical records of HIV-infected pregnant women who received HAART during pregnancy in the period 1 January 1997-1 June 2003 at 14 HIV-specialized centres in the Netherlands. The inclusion criteria were at least a triple drug regimen and birth at 20 or more weeks of gestation. Information was collected about patient characteristics, HAART prescribed, side effects, viral load response, mode of delivery and HIV-status of the neonate., Results: A total of 267/413 women satisfied the inclusion criteria. Most women (n = 199) had not previously received anti-retroviral therapy and started HAART between weeks 21 and 28 of the pregnancy. The two most frequently used regimens contained nelfinavir (57%) or nevirapine (31%). Gastrointestinal side effects were more frequently observed in the nelfinavir group, while rash and hepatotoxicity were more frequently reported in the nevirapine group. Efficacy and pregnancy outcome were similar in both groups. Two infants (0.7%) were HIV-infected., Conclusion: HAART regimens containing nelfinavir or nevirapine in HIV-infected pregnant women were safe, effective and well tolerated.

Objective: To assess adherence to antiretroviral therapy (ART) in Dutch and non-Dutch HIV-infected patients., Design: Observational, cross-sectional study., Methods: Consecutive HIV-infected patients taking ART and visiting the internal medicine outpatients' clinic at the Rotterdam Dijkzigt University Hospital between 1 February until 30 April 2001 were interviewed by a multilingual interviewer using a standard questionnaire. Classification of adherence was based on the interview data. Multivariate analysis was used to determine independent predictors of adherence. Nationality was defined as 'Dutch' if the person was born in the Netherlands, and otherwise as 'non-Dutch'., Results: The 203 patients included in this study comprised 131 men and 69 women with an average age of 42 years. There were no data available on treatment adherence for 3 of the patients. Of the 81 Dutch patients, 60 (74%) adhered to the treatment compared with 68 (57%) of the 119 non-Dutch patients. However, after correction for sex, risk group, race and duration of treatment, there was no difference in treatment adherence between these two groups (OR: 0.6; 95% CI: 0.2-1.9). Failure to adhere to treatment was seen most frequently in the 109 heterosexually infected patients (OR: 2.6; 0.98-6.7), the 22 intravenous drug users (OR: 3.3; 1.04-10.1), as well as in the group of Negroid patients (OR: 3.5; 1.1-11.3) and Latin-American patients (OR: 8.5; 1.7-42.7).

Objective: To evaluate the effect of treatment of HIV-1 infection with combination therapy consisting of since 1996 in the Netherlands available protease and reverse transcriptase inhibitors., Design: Prospective cohort study., Methods: In an observational clinical cohort of HIV-1-infected individuals, the short-term successful treatment end point of antiviral therapy including at least one antiretroviral drug licensed in the Netherlands since July 1, 1996 (protease inhibitors and reverse transcriptase inhibitors), was HIV-1 RNA plasma levels < or = 500 copies/ml (virological success). Cox proportional hazard models were used to identify prognostic markers for therapy success. The study included 2,148 infected individuals with a median follow-up of 135 weeks of treatment; 1,049 had been pre-treated with antiretroviral drugs before starting their new regimen and 1,099 were treatment naive., Results: Plasma HIV-1 RNA levels < or = 500 copies/ml at 24 weeks of treatment were seen in 61% of all patients. The chance of therapy success for naive patients was twice that for pre-treated patients (relative risk: 1.8; p < or = 0.001). Following the first 24 weeks, the chance of virological success was higher in the naive group (78% versus 63%; p < or = 0.001), and the number of naive patients failing therapy after initial success was smaller compared to pre-treated patients (22% versus 45%; p < or = 0.001). In the naive group, the CD4+ T-cell number increased from 239 to 440 (x 10(6) cells/l) in case of success, and decreased from 150 to 320 in case of treatment failure. HIV-1 related morbidity declined from 0.26 to 0.05 and mortality dropped from 0.07 to 0.03 per person-year of follow-up. Regimens were changed at least once in 76% of patients. Toxicity and therapy failure were the main reasons for regimen changes in naive and pre-treated patients, respectively., Conclusion: A combination of antiretroviral drugs, including at least one of the drugs licensed since 1996, led to a drop in HIV-1 plasma concentrations. Morbidity and mortality also decreased. The chance of a better immunological and virological response to the new drug regimens was greatest in therapy-naive patients.

In three patients, a 36-year-old HIV seropositive homosexual man and two women aged 35 and 59 years who had acquired HIV infection through heterosexual contact, signs of lipodystrophy developed after prolonged anti-HIV triple therapy. The observed syndrome is seen after prolonged use of HIV protease inhibitors: it is characterized by peripheral fat wasting, central fat accumulation, hyperlipidaemia and insulin resistance. Typically the subcutaneous fatty tissue disappears resulting in prominent zygomata, veins and muscles and thinning of extremities and buttocks. In addition to abdominal fat accumulation, there have been reports on the occurrence of a dorsocervical fat pad, the so-called buffalo hump. Lipodystrophy caused by protease inhibitors is a risk factor for cardiovascular disease. Recognition of the syndrome is essential for adequate follow-up and possible treatment.

Objective: To illustrate how clinical decision analysis can contribute to modern medical practice., Design: Clinical decision analysis., Setting: Academic Hospital Rotterdam-Dijkzigt, Rotterdam, the Netherlands., Method: Three treatment options (no treatment, neurosurgery and radiosurgery) for a 60-year-old HIV-positive woman with a once-ruptured cerebral arteriovenous malformation were compared using clinical decision analysis, with respect to the discounted quality adjusted life expectancy. Estimates of the risk of bleeding and its complications, of the efficacy and complications of treatment, and of the risk of developing AIDS and its consequences were based on the clinical literature., Results: Differences between no treatment and neurosurgery or radiosurgery amounted to 0.1 (plausible range: -0.27 to 0.84) and 0.2 (plausible range: -0.29 to 0.76) discounted quality adjusted life years, in favour of no treatment. The limited life expectancy of the patient, leading to a relatively low cumulative risk of haemorrhage, did not appear to justify the risks of treatment., Conclusion: Clinical decision consultation may provide a rational, thorough and explicit decision procedure which takes into account the complexity of medical care.

In two women (aged 30 and 39), both addicted to heroin and HIV seropositive, cervical intraepithelial neoplasia and infiltrating squamous cell carcinoma of the cervix respectively were diagnosed. Treatment consisted of exconisation and radiotherapy respectively. Adding invasive cervical carcinoma to the AIDS-defining conditions and CIN II and CIN III to the symptomatic HIV-related conditions emphasis the importance of gynaecological care for HIV-infected women. Clear treatment guidelines for distinct patient groups still have to be defined.

Objective: To evaluate the characteristics of HIV infected patients in the Rijnmond region during 1985-1993., Design: Descriptive., Setting: University Hospital Rotterdam-Dijkzigt (AZR)., Method: Data of medical records of all HIV infected patients in AZR were prospectively collected from 1988 on and retrospectively for 1985-1987., Results: During the period 1985-1993 510 HIV positive patients consulted an internist at AZR (eight were infected with HIV-2). During the study 255 patients developed AIDS. Since 1991 fewer than 50% of the new HIV infected individuals belonged to the risk group of homosexual and bisexual men. The majority was infected by intravenous drug abuse or by heterosexual intercourse. Half the population infected by heterosexual transmission came from HIV endemic areas. The increasing number of HIV infection among heterosexuals was associated with an increasing number of HIV infected women., Conclusion: The Rijnmond region showed a noticeable shift of risk groups with HIV infection: heterosexual transmission and intravenous drug abuse were the cause of HIV infection in more than half of the HIV infections at AZR in 1992 and 1993. Counselling, health care and treatment should take account of the diversity of cultural backgrounds of the patient groups.

In the period 1985-1990, 111 patients with AIDS were treated in the University Hospital Rotterdam-Dijkzigt. In 8 out of 111 patients malignant non-Hodgkin lymphoma developed. The unusual and bizarre representation is highlighted by several clinical histories and a review of literature. HIV-related non-Hodgkin lymphoma is characterized by widespread extranodal disease, often at unusual sites, and high grade B-cell malignancy. The therapeutic outcome and survival in these cases has been disappointing. Prognosis is better for patients without a prior AIDS diagnosis, higher total CD4 cell counts, good performance score and absence of an extranodal site of disease. Treatment should be tailored to individual patients based upon a variety of prognostic features.

In four patients in Rotterdam AIDS was diagnosed, and it was subsequently demonstrated that they were infected with HIV type 2. One of the patients was an immigrant from the Cape Verde islands, two of the others had heterosexual contacts with persons of this area, and the fourth patient was a male homosexual without known contacts with Africans. The Cape Verde islands are one of the areas in which HIV-2 infection occurs, and because of immigration into The Netherlands and in particular to Rotterdam, the possibility of HIV-2 infection should be considered in persons of this population group and their sexual contacts. Furthermore, problems with serologic investigations should be avoided by the application of HIV-2 specific confirmatory assays.