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Objectives: Antiretroviral therapy (ART) has immense survival benefit on human immunodeficiency virus (HIV)-infected people. However, every year, a proportion of patients were failing to the first-line drugs. The aim of this study is to characterize the patients developing first-line failure within 5 years of ART. Materials and Methods: A retrospective observational study was carried out at the Centre of Excellence in HIV care, School of Tropical Medicine, Kolkata. A total of 190 referred patients' data of suspected first-line treatment failure who failed first-line ART within 5 years of initiation were collected and analyzed using R software. Results: Among 190 patients, 100 (52.4%) patients had virologic failure. Male patients 78 (41.05%) outnumbered females 22 (11.57%) and needed to switch to the second-line drugs. The median age was 37 years (range 8–65 years), and the median duration of first-line ART taken was 2.85 years. Among the first-line failed patients, zidovudine, lamivudine, and nevirapine (23.6%) was the most common antiretroviral regimen and 77 (40.5%) referred in the WHO stage I of illness. Seventy-three (38.42%) patients were referred for immunological failure, 26 (13.7%) for both immunological and clinical failure, and only 1 (0.52%) had only clinical failure at the time of referral. We found a significant association of suboptimal adherence (P < 0.05) and high viral load in this study. Conclusion: This study enables that poor adherence was the most important factor responsible for the first-line treatment failure. As adherence is a dynamic process, interventions in every visit following ART initiation should be optimized, and a multidisciplinary approach toward adherence is needed to get the highest treatment outcome benefit.

Introduction and Objectives: A common adverse effect of Efavirenz (EFV) – a first line drug used in treatment of patients with HIV infections is skin rash. In case of EFV-induced skin rash, the usual practice is to switch to a Protease Inhibitor (PI), as another non-nucleoside reverse transcriptase inhibitor (NNRTI) might have cross-­reactivity with a higher incidence of skin rash which is often severe. The aim of the study was therefore to determine whether with careful evaluation and stratification, using pre­defined criteria of patients who developed rash with EFV, it might be possible to find a subset of patients among whom Nevirapine (NVP) may be safely used, sparing PIs for second-­line treatment. Methods: Of 7000 ART naive patients initiated on EFV in an 18 month period from November 2014 to April 2016, 97(1.9%) developed a rash. Patients developing rash with EFV were carefully selected using pre­defined criteria: grade of rash (only Grade I/II rash were selected), hepatic function, age, gender and CD4 levels (males > 400 cells/cmm and females >250 cells/cmm were excluded if hepatic function was deranged), co­-infection status (Hepatitis B/C were excluded), opportunistic infections, concomitant use of other drugs. Based on these stratification criteria, 23 of the 97 patients were selected for challenge with NVP. Results: Of the 23 selected patients, only 3 (13%) patients developed recurrence of rash, all being mild in nature. Conclusions: In carefully selected patients, challenge with NVP can be done in case of rash with EFV as the theory of cross­-reactivity does not always hold true. This might help spare PIs in the initial phase, which could then be used as second line therapy - a particularly helpful strategy in developing countries, where newer drugs are still not available under public health programmes.

Introduction Disseminated histoplasmosis is a treatable common opportunistic infection in HIV infected people and not uncommon in others in a tropical country like India. The objective of our study was to evaluate clinical-pathological correlation and treatment outcome of disseminated histoplasmosis treated with conventional Amphotericin B in an endemic area.Material and methodsThis was a retrospective observational study of twenty-two cases of disseminated histoplasmosis admitted to a tertiary care hospital from January 2009 to December 2012 and treated with Amphotericin B followed by oral Itraconazole therapy for one year. Results of treatment outcome including relapse and mortality were analyzed in January 2014.ResultsHistoplasmosis was diagnosed in patients with advanced HIV (72%) illness with a mean CD4 count of 63.43/l. Tuberculosis and diabetes were other co-morbid illnesses and it was less common among immunocompetent patients (9%). Fifty percent of the patients presented with cutaneous lesions along with systemic manifestations while 27% had only mucocutaneous lesions. Adrenal histoplasmosis (18%) was common in HIV negative subjects. HIV positive patients showed excellent response to Amphotericin B followed by Itraconazole therapy. In 27% HIV positive patients, the disease manifested as IRIS (immune reconstitution inflammatory syndrome). Relapse was seen in 2(9%) patients. After one year of completion of therapy 16 patients were cured, 3 patients (13.6%) died in the early part of treatment and one was lost to follow up. Treatment response in HIV infected patients showed excellent results but long term maintenance itraconazole therapy was inevitable (12-32 months).ConclusionsIt is concluded that early diagnosis and treatment can prevent a fatal disease like disseminated histoplasmosis with conventional Amphotericin B followed by Itraconazole. Adrenal histoplasmosis was common among the HIV negative population. Extensive follow up is required to identify early relapse which may need further prolongation of therapy for cure.

Although cases of Selective Serotonin Reuptake Inhibitor (SSRI) induced akathisia have often been reported in literature, this adverse effect has not adequately been mentioned in major pharmacology textbooks. As a result, SSRIinduced akathisia is very frequently under-recognized. A review of literature showed that almost all frequently used SSRIs such as Fluvoxamine, Fluoxetine, Sertraline, Citalopram have been reported to be causing akathisia. SSRI-induced restless legs syndrome and movement disorders have also been reported. However, Escitalopram-induced akathisia is rare. In our review of literature, we could find only one single case of Escitalopram-induced severe akathisia. And this specific SSRI drug has rarely been implicated with occurrence of restless legs syndrome and extra-pyramidal side-effects like dytonia etc. Here, we present a case of Escitalopram-induced severe akathisia - a 53year old female, who had developed severe akathisia after taking Escitalopram for a few days. According to the Barnes Akathisia Rating Scale (BARS), her Global Clinical Assessment of Akathisia Score was 5 i.e. severe akathisia. As per Naronjo Adverse Drug Reaction Scale the probability of association of this adverse reaction with Escitalopram was 7 (i.e. probable). Her symptoms continued in spite of prompt discontinuation of the drug. But, she improved rapidly with the use of Propranolol and Clonazepam. On the last follow-up, she was free from any symptoms. As new generation antidepressants are rarely associated with extra-pyramidal symptoms, the recognition of such adverse effects requires a high index of suspicion. Early recognition of the symptoms and discontinuation of the offending agent along with supportive therapy like a short course of benzodiazepines, beta-adrenergic antagonists or anticholinergics may rapidly relieve the patient from this distressing symptom.

Aim Hypersensitivity to the anti-retroviral agents is a common problem encountered in the treatment of HIV/AIDS patients. However, in resource-limited settings, where only fixed-dose combinations of the drugs are the only available option and expensive facilities of pharmacological analysis are not available, isolating the offending agent can be a challenging task. Background We, at our centre, follow a protocol to isolate such offending drug – a protocol of gradual de-challenge and re-challenge – by a method of exclusion. Materials and Methods Here, we have described a series of four cases, providing examples of usage of our own protocol to isolate the offending drug by a method of exclusion. Results and Conclusion In a resource-limited setting, where we have to use fixed-dose combination of anti-retroviral agents, management of a patient with drug hypersensitivity is a problem. Our protocol of systematic de-challenge and re-challenge, as exemplified in these cases, can be of help where expensive facilities are not available.

There is a large concentration of chemical firms around Mumbai, and the Maharashtra Pollution Control Board has been actively monitoring them. Such monitoring is likely to have an impact on the productive efficiency of these firms. The firms argue that additional costs to minimise environmental damage have reduced their efficiency. We try to find out whether these water-polluting firms in the chemical industry around Mumbai are actually unable to cope with the additional cost of pollution abatement, or whether by using cleaner practices, are able to improve their efficiency, and support the ‘win-win’ opportunities as claimed by the Porter Hypothesis. The study is carried out by estimating an Output Distance Function using a stochastic production function. The panel data of fifty water-polluting small-to medium-scale firms for three-year period of 2004–06 was collected in a primary survey of chemical industries around Mumbai. We find that the polluting firms are technically more efficient than those firms which adhere to pollution norms. Thus, the Porter Hypothesis does not hold for the sample.

Methods Data of patients referred to School of Tropical Medicine, Kolkata for suspected treatment failure (TF) was analyzed for the period of December2008 to November2013 to ascertain the positive predictive value (PPV) of immunologic and/or clinical parameter for confirming virologic failure (VF) and to observe the short term outcome of secondline treatment. Paired ttest was used for data analysis.