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Little is known about how the prevalence and incidence of neurological disease in HIV-infected patients in resource-limited settings. We present an analysis of neurological and neurocognitive function in antiretroviral naive individuals in multinational resource-limited settings. This prospective multinational cohort study, a substudy of a large international randomized antiretroviral treatment trial, was conducted in seven low- and middle-income countries in sub-Saharan Africa, South America, and Asia. Subjects were HIV-infected and met regional criteria to initiate antiretroviral therapy. Standardized neurological examination and a brief motor-based neuropsychological examination were administered. A total of 860 subjects were studied. Overall 249 (29%) had one or more abnormalities on neurological examinations, but there was a low prevalence of HIV-associated dementia (HAD) and minor neurocognitive disorder (MND). Twenty percent of subjects had evidence of peripheral neuropathy. There were significant differences across countries (p

Background: A great deal of effort has been devoted to understanding the role of AIDSassociated mycoplasmas in recent years. However, the role of Mycoplasma pneumoniae in HIV disease remains unclear. Methods: We studied 300 adult HIV infected persons (200 with community-acquired pneumonia (CAP) and 100 with no respiratory illness) and 75 HIV uninfected persons with CAP and analysed the prevalence of respiratory pathogens. Results: Prevalence of M. pneumoniae was 17% by induced sputum and 11.3% by throat swab culture in HIV positive subjects. Seroprevalence of anti-M. pneumoniae IgM was 11.7% by ELISA and 14.3% by gelatin microparticle agglutination test. Prevalence of M. pneumoniae among HIV negative cases was relatively low. Streptococcus pneumoniaewas predominant (28%) among subjects with lower respiratory disease, whereas Staphylococcus aureus (15%) was more common among cases with upper respiratory illness. Rales (P=0.001), pharyngeal erythema (P=0.02), cervical adenopathy (P=0.004) and crepitations (P=0.001) showed significance in relation to M. pneumoniae positivity. Statistical significance was observed with regard to total lymphocyte count (P=0.02) and erythrocyte sedimentation rate (P=0.04), and M. pneumoniae positivity. Conclusion: The prevalence of M. pneumoniae in HIV infected subjects was relatively higher than HIV uninfected subjects with respiratory disease.

The aim of the article is to compare the clinical and behavioural characteristics of HIV-infected South Indian patients in concordant and discordant heterosexual relationships. A cross-sectional analysis of married couples in concordant and discordant relationships was carried out. Demographic and clinical characteristics, sexual behaviours, CD4 cell count and plasma HIV-1 RNA loads were assessed. A total of 839 concordant patients and 996 discordant patients were included in this analysis. Significantly more men were in discordant than concordant relationships (97% versus 59%; P = 0.002). More discordant patients had never initiated highly active antiretroviral treatment (HAART) than concordant patients (14.1% versus 8.5%; P = 0.004). Concordant patients had significantly higher CD4 cell counts than discordant patients at the time of enrolling to care (205 versus 139 cells/μL; P = 0.001). Discordant patients had significantly higher plasma viral loads than concordant patients (100,000 copies/mL versus 89,154 copies/mL; P = 0.002). Discordant patients were more likely to use condoms with their spouses than concordant patients (49% versus 28.8%; P = 0.01). In conclusion, couples-based interventions and the provision of HAART could substantially decrease behavioural and clinical correlates of HIV transmission among discordant South Indian married couples. The spouses of HIV-infected index patients are at increased risk for HIV infection, and further preventive measures are needed.

Department of Infectious Diseases,YRG Centre for AIDS Research and Education (YRG CARE),VHS Hospital Campus, IT Corridor, Taramani,Chennai 600 113, India.Tel.: +91 (44) 22542929E-mail: sundaram@yrgcare.orgDear Editor,Electrolyte disturbance can be associated with numerousmorbid conditions especially among HIV-infected individualsreceiving highly active antiretroviral therapy (HAART) (1- 4).Electrolyte imbalance is described to be the prime cause ofdeath due to myriad infectious ailments involving thegastrointestinal tract, exemplified by Asiatic cholera, rota virusinfection, shigellosis, salmonellosis, leptospirosis, malaria andparasitic diarrhoea. Unless restored, electrolyte imbalance canbe serious and might interfere with a patient’s immuneresponse. T erminal HIV disease is characterized by the onsetof numerous opportunistic infections (OI) and neoplasms andindividuals in terminal AIDS are vulnerable to numerousintracellular infections, where the corresponding aetiologicalagents reportedly use the intracellular elements (e.g. iron) andmetabolites to survive and replicate, which likely alters theevents related to cellular metabolism (5). This couldsubsequently lead to a plethora of functional sabotage eventsin cellular and immune functions (5). Maintenance of anoptimum amount of electrolyte (ionic homeostasis) in theintracellular as well as the extracellular compartment (blood,interstitial fluid etc.) is paramount to healthy living. Electrolyteimbalance could be attributed to numerous factors both fromthe host as well as from the parasite point of view andprincipally reflects a disturbance in the host’s cellular metabolicpathways possibly after establishment of an infection.In the post-HAART era, information of the prevalence ofelectrolyte imbalance is limited both in developed world aswell as in resource-limited settings and has never beenadequately investigated. One study has identified abnormallylow bicarbonate levels (1) and another documented HIV-associated nephropathy (2) among HAART-treated HIVpositive persons. Few others have documented that HIV-infected individual with underlying OIs treated with HAARTregimens developed biological abnormalities includinghyponatraemia, hyperkalaemia or hypokalaemia and acidosis(3, 4). Besides, sodium and potassium imbalances arebelieved to be associated with a plethora of chronic ailments,such as malnutrition, alcoholism, diabetes mellitus and otherinfectious causes especially in AIDS. A detailed literaturesurvey revealed the availability of very limited past data onthe prevalence of electrolyte imbalances in HIV infectedindividuals. Further, the underlying risk factors for biologicalabnormalities are poorly defined. Hence in a cross-sectionalstudy we investigated the proportion of HIV infected personswith abnormal serum electrolytes and identified the possibleco-factors of these biological abnormalities among personsattending YR Gaitonde Centre for AIDS Research andEducation (YRG CARE), a tertiary referral centre in SouthernIndia, between January 2004 and July 2006. Data werecollected with the approval of YRG CARE’s freestandinginstitutional review board.YRG CARE, since 1993, has provided medical andpsychosocial care and support to over 12,000 HIV-infectedpersons in the south of India. The study was approved by theInstitutional Review Board (IRB) of YRG CARE. Writteninformed consent was obtained from all the participants. Weinvestigated 464 HIV-infected persons who were either HAARTnaive or HAART experienced. Demographics, clinicalcharacteristics and co-factors (age, gender, hepatitis B and Cstatus and exposure to HAART) were included in the analysis.Laboratory investigations such as electrolytes (sodium,potassium, chloride and bicarbonate) and absolute CD

To assess the risk factors associated with heterosexual HIV transmission among South Indian discordant couples enrolled in clinical care.A nested matched case-control study of serodiscordant couples in which the HIV-infected partner (index case) was enrolled in care. Demographic and clinical characteristics, sexual behaviours, CD4 cell count and plasma HIV-1 RNA loads were measured at enrollment and longitudinally over 12 months of follow-up. The study included 70 cases who seroconverted during study follow-up and 167 matched controls who remained persistently serodiscordant.The incidence of HIV infection among the initially seronegative partners was 6.52 per 100 person-years. Persistently discordant patients were more likely to have initiated highly active antiretroviral therapy (HAART) than patients in seroconverting relationships (62.9%vs. 42.9%) (P=0.001). Patients in seroconverting relationships had significantly higher plasma viral loads (PVLs) than patients in discordant relationships at enrolment, at 6 months and at 12 months (P0.05). Patients in seroconverting relationships were less likely to use condoms with their primary partners than patients in discordant relationships (P0.05). Patients in relationships that seroconverted between 6 and 12 months were diagnosed more often with genital Herpes simplex than patients in discordant relationships (P=0.001). In the univariate and multivariate logistic regression, the following variables were associated with seroconversion: PVL100,000 [odds ratio (OR): 1.82; 95% confidence interval (CI): 1.1-2.8], non-disclosure of HIV status (OR: 5.5; 95% CI: 4.3-6.2) and not using condoms (OR: 2.8; 95% CI: 2.4-3.6).Couples-based intervention models are crucial in preventing HIV transmission to seronegative spouses. Providing early treatment for sexually transmitted infections, HAART and enhancing condom use and disclosure could potentially decrease the risk of HIV transmission within Indian married couples.

Anaemia accelerates disease progression and increases mortality among HIV-infected individuals. Few studies have characterized this problem in developing countries. Haemoglobin values of adults presenting to an HIV tertiary care center in India between 1996 and 2007 were collected (n = 6996). Multivariate logistic regression analysis was performed to examine associations among anaemia, HIV progression and co-morbidities. Overall, anaemia prevalence was 41%. Twenty percent of patients with CD4 counts >500 cells/μL were anaemic, compared with 64% of those with CD4 counts P < 0.001). In multivariate analysis, CD4 count

Continuation of failed highly active antiretroviral therapy regimens can lead to the accumulation of mutations that may limit options for second-line treatment. We studied the pattern of drug resistance mutations among 138 Indian patients who experienced failure of nonnucleotide reverse-transcriptase-containing first-line highly active antiretroviral therapy. This study demonstrates a high frequency of drug resistance mutations in human immunodeficiency virus-infected Indians who experience immunologic treatment failure and suggests the need for viral load monitoring.

This study sought to examine gender-based differences in the quality of life of men and women living with HIV in South India in the era prior to greater access to antiretroviral therapy. The participants in this prospective longitudinal study consisted of 215 men and 141 women who were administered a quality of life (QOL) instrument comprising five scales: physical well-being, psychosocial well-being, sexual well-being, satisfaction with health care, and strength of partner relationship. Interviews were conducted at enrollment and at 6 months in clinical care. Men and women reported similar scores in physical well-being, satisfaction with health care, and relationship with partner from the period prior to care, at enrollment, and at 6 months. Women scored significantly lower than men in psychosocial well-being from the period prior to care, at enrollment, and at 6 months (p

To describe gender-based differences in disease progression, treatment, and outcome among patients receiving highly active antiretroviral therapy (HAART) in South India.Therapy-naïve patients initiating HAART between February 1996 and June 2006 at a tertiary HIV referral center in Chennai, South India, were analyzed using the YRG CARE HIV Observational Database. Patients with 1 year of follow-up after initiating HAART were examined to investigate immunological and clinical outcomes, including the development of adverse events to therapy and opportunistic infections.All previously therapy-naïve patients who initiated HAART with at least 1 year of follow-up (n = 1972) were analyzed. At enrollment into care, women had higher CD4 counts, lower hemoglobin, and higher body mass index (BMI) than their male counterparts (p0.05). At the time of initiating therapy, women had higher CD4 counts and lower hemoglobin (p0.05); women continued to have higher CD4 counts at 12 months (p0.05). After 1 year following HAART initiation, significantly more men developed tuberculosis and Pneumocystis jiroveci pneumonia (p0.05), more women experienced lactic acidosis and nausea, and more men developed immune reconstitution syndrome (p0.05).Significant physiological, immunological, and clinical differences exist between men and women initiating HAART in a resource-limited setting in South India. Future studies should examine whether clinical management strategies should be different for men and women in resource-limited settings.

This case report documents that highly active antiretroviral therapy (HAART) can lead to the regression of Kaposi's sarcoma (KS) lesions in the auditory canal of an HIV-infected male from Chennai, India. In resource-limited settings where administering anti-KS chemotherapeutic agents may not be feasible, HAART alone can be an option in HIV-infected individuals with KS.

SummaryObjectiveTo describe the causes of mortality among the HIV-infected in southern India in the era of highly active antiretroviral therapy (HAART).MethodsAnalyses of this patient cohort were conducted using the YRG Centre for AIDS Research and Education HIV Natural History Observational Database. Causes of death were then individually confirmed by patient chart review.ResultsSixty-nine deaths occurred within the inpatient unit; 25% were female and the median age of the 69 patients was 34 years. Over half of the patients (55%) died within three months of initiating HAART. At the time of enrollment into clinical care, the median CD4 cell count was 64 cells/μl (interquartile range (IQR) 37–134). At the time of initiating HAART, the median CD4 cell count was 58 cells/μl (IQR 31–67) for patients who died within 3 months of initiating HAART and 110 cells/μl (IQR 77–189) for patients who died more than 3 months after initiating HAART. Close to three-fourths of patients (70%) died from an AIDS-defining illness (ADI). The major ADI causes of death included Pneumocystis jiroveci pneumonia (22%), extrapulmonary tuberculosis (19%), CNS toxoplasmosis (12%), and pulmonary tuberculosis (10%). A tenth of patients died from cerebrovascular infarcts. Three patients (4%) died from non-Hodgkin lymphoma.ConclusionsAIDS-related events continue to be the major source of mortality among the HIV-infected in southern India in the era of HAART. This mortality pattern justifies increased proactive efforts to identify HIV-infected patients and initiate HAART earlier, before patients present to care with advanced immunodeficiency.

Summary: This case history documents four instances of HIV secondary transmission within a single family, which could have been stopped at multiple points by timely prevention. These cases of HIV secondary transmission that have occurred since the scale-up of HIV testing, prevention and clinical services in India raises the question whether the current HIV prevention infrastructure is sufficient and comprehensive in resource-limited settings.

To determine the incidence of clinically significant adverse events after long-term, fixed-dose, generic highly active antiretroviral therapy (HAART) use among HIV-infected individuals in South India, we examined the experiences of 3154 HIV-infected individuals who received a minimum of 3 months of generic HAART between February 1996 and December 2006 at a tertiary HIV care referral center in South India. The most common regimens were 3TC + d4T + nevirapine (NVP) (54.8%), zidovudine (AZT) + 3TC + NVP (14.5%), 3TC + d4T + efavirenz (EFV) (20.1%), and AZT + 3TC + EFV (5.4%). The most common adverse events and median CD4 at time of event were rash (15.2%; CD4, 285 cells/microL) and peripheral neuropathy (9.0% and 348 cells/microL). Clinically significant anemia (hemoglobin7 g/dL) was observed in 5.4% of patients (CD4, 165 cells/microL) and hepatitis (clinical jaundice with alanine aminotransferase5 times upper limits of normal) in 3.5% of patients (CD4, 260 cells/microL). Women were significantly more likely to experience lactic acidosis, while men were significantly more likely to experience immune reconstitution syndrome (p0.05). Among the patients with 1 year of follow-up, NVP therapy was significantly associated with developing rash and d4T therapy with developing peripheral neuropathy (p0.05). Anemia and hepatitis often occur within 12 weeks of initiating generic HAART. Frequent and early monitoring for these toxicities is warranted in developing countries where generic HAART is increasingly available.

This chapter reviews India's response toits HIV epidemic. It argues that the provision of prevention and treatment services for HIV-infected people through non-government organizations (NGOs) or the private sector is not an adequate solution in the Indian context. The scale of operations required; the social, religious, economic, and geographical heterogeneity of India; and the low income of the majority of India's citizens mean that the only solution to effective prevention and treatment of HIV infection is to develop public systems linked with community support structures.

We investigated 245 diarrheal stool specimens from HIV-positive subjects between January 2003 and December 2006 to determine the etiological role of coproparasites. Parasitic etiology was observed in 91 (37.1%) cases. Isospora belli (26.1%) was the most common parasite followed by Entameba histolytica/dispar (3.3%), Cryptosporidium spp. (2.9%), Giardia intestinalis (1.6%), and Strongyloides stercoralis (1.2%). Interesting trends of significant increase in the number of cases of I. belli and decline in Cryptosporidium spp. were observed during the study period.

Apart from the more or less distinctive forms of periodontal disease associated with human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome there remains considerable uncertainty as to whether or not conventional destructive periodontitis is exacerbated in HIV positive individuals. This is especially so in developing countries, from which few studies have been reported. The present study compared the severity and extent of periodontal breakdown in 136 HIV positive individuals from Chennai, South India, with 136 age-matched controls from the same low socio-economic and ethnic group. All surfaces of all teeth were scored for the community periodontal index of treatment needs (CPITN). Statistical analysis was performed using SPSSTM package. The results of the present study show that CPITN is a simple, useful technique to assess periodontal status in immunosuppressed patients and that periodontitis is associated with immunosuppression and oral candidiasis. The assessment of periodontal status could thus be a useful tool in minimally invasive screening of populations for HIV disease, especially in those parts of the world, like India and Africa, with high prevalence and rising incidence.

The advent of highly active antiretroviral therapy (HAART) has changed the scenario of human immunodeficiency virus (HIV) infection. HIV patients in India have now access to generic HAART and this is the first report describing oral lesions in patients on HAART from our country.Oral lesions were studied in HIV seropositive patients (n = 50 on HAART and n = 50 not on HAART) attending a tertiary HIV referral care centre in India and patients on HAART were followed up.There was a difference in the occurrence of oral candidiasis (OC) between HAART and non-HAART participants (8%, 24%; P0.05). Pseudomembranous candidiasis was 4% and 18% in HAART and non-HAART groups respectively (P0.05). In patients with CD4 countor=200, OC was 5.6% in the HAART group and 39.1% in the non-HAART group (P0.05). Among patients with CD4 count200, pigmentation was 43.8% in the HAART group and 14.8% in the non-HAART group (P0.05).The prevalence of OC in patients who had access to HAART was less when compared with those who did not have access to HAART.

The neurocognitive impact of the clade C viral strain of human immunodeficiency virus (HIV) has not been determined. The purpose of this study was to examine neurocognitive function in southern India among individuals with the clade C virus with advanced HIV. A battery of cognitive tasks sensitive to the effects of HIV on brain function was translated and administered in Tamil and Telegu, two widely spoken languages in southern India. A sample of 30 treatment-naive HIV-positive individuals with a median CD4 cell count of 97, and 30 age and education matched healthy controls obtained from the same region of India, were included in the study. Results revealed significant differences on most cognitive tests, with lower performances obtained by the HIV-positive individuals. These results suggest that cognitive difficulties are present among individuals with the clade C virus in India, with as many as 56% of the patients with advanced HIV meeting the criterion for impairment in two cognitive domains. Additional study is needed to determine if clade C HIV infection is more or less prone to cause neurocognitive deficit than the clade B virus. Furthermore, the impact of antiretroviral therapy on neurocognitive dysfunction in clade C virual infection needs to be determined.

Little research exists on acceptability issues related to assessments of adherence to ART in resource-poor settings. To help prepare for two large-scale, multisite ART intervention trials, this qualitative study of individuals in Chennai, India (49 men, 11 women; 33 taking ART, 27 not) and Lilongwe, Malawi (5 men, 5 women, all taking ART) examined potential limitations of different types of adherence assessments: an adherence questionnaire, a pill diary, a pillbox, an electronic pill cap, and a medication punch card. Many participants reported that the various assessments would be acceptable. Potential limitations included issues surrounding literacy, the desire to appease one's medical provider, privacy and stigma, and "cheating." These potential limitations are similar to the limitations of these assessments in Western settings. However, the data highlight the need to consider individual patient level concerns when assessing ART adherence in different cultural settings. Innovative ways of monitoring adherence while maintaining standardization across sites are required in multisite trials.

Human immunodeficiency virus (HIV) observational cohorts, which are established worldwide, support comparative studies across different regions. They have played an important role in developing international and country-specific HIV treatment and care guidelines. We describe the YRG CARE Chennai HIV observation database (YCHOD) and highlight its utility in monitoring trends in antiretroviral treatment use and HIV disease outcomes in India.The baseline characteristics, time trends in antiretroviral treatment, trends in incidence of acquired immune deficiency syndrome (AIDS)-defining illness and mortality following the introduction of highly active antiretroviral therapy (HAART) in India were assessed using YCHOD.Till January 2005, 7647 HIV-positive patients had registered in YCHOD. A majority of the patients were men (69%) and had a mean age of 32 years. At baseline, 14% had an existing AIDS-defining illness. Among patients who required therapy by the WHO criteria, 14% initiated antiretroviral therapy (ART) in 1996 and 35% in 2000. Since the dramatic cost reduction of generic HAART in 2001, there has been an increase in the proportion of patients receiving ART to 57% in 2004. In patients who were started on HAART, the incidence of at least one AIDS-defining illness was 2% in 2001, and this decreased to 0.48% in 2004.We feel observational cohorts are useful as a surveillance tool for monitoring trends in treatment and disease progression. Standardized observational data collected systematically on HIV-infected individuals will help to assess the cost-effectiveness of ART and in planning ART strategies for India.

Materials and methods The present study has been carried out on 60 HIV infected patients presenting with underlying pulmonary complaints and whose clinical presentation was consistent with disease caused by Mycoplasma pneumoniae, after obtaining informed consent subsequent to approval by the Institutional Review Board (IRB) on human ethics in Chennai where the recovery rates of Mycoplasma pneumoniae from induced sputum and throat swab specimens of HIV infected patients were compared and the haematological and immunological findings were analysed. Patients screened were from the age groups ranging from 15 to 60 years, whose respiratory specimens were cultured on PPLO glucose agar and broth, the later with 1% methylene blue. Presumptive identification of Mycoplasma pneumoniae was carried out using guidelines proposed by the Subcommittee on the Taxonomy of Mollicutes, 1979. The respiratory specimens from the HIV-infected subjects were later analysed for their recovery rates, incidence of other bacterial, fungal pathogens, AFB, Pneumocystis carinii and their correlation features with CD4+ and CD8+ lymphocytes were also analysed and compared.

The Western blot assay is the gold standard for the detection of antibodies to human immunodeficiency virus type 1 (HIV-1). However, indeterminate Western blot reactivity to HIV-1 proteins may occur in individuals, who may not be infected with HIV.This retrospective study was aimed to determine the diagnostic value of the interpretation criteria in relation to commercial kits for HIV-1 diagnosis.A total of 556 serum/plasma specimens collected from high-risk population attending our HIV clinic from 2000-2004 were tested by three different western blot kits: NEW LAV BLOT I (n=244), HIV BLOT 2.2; (n=112), Genetic Systems HIV-1 (n=237). And the results of western blot strips were analyzed using the various interpretation criteria: WHO/NACO, CDC/ ASTPHLD, ARC, FDA, CRSS and JHU. Some specimens were run on more than one kit. RT-PCR assay was performed on 5 specimens, which were indeterminate with LAV BLOT I.The discrepancy in LAV BLOT I positive results were between 157(64)-176(72), and indeterminate results were between 44(18) to 63(25). No such variations were observed in genetic systems. There are some HIV negative (by PCR) specimens were indeterminate in LAV BLOT I revealing the kit more sensitive and less effective for diagnostic purpose.The genetic systems kit is superior to other kits we analyzed and its results are concordant with HIV-1 PCR results. To report, the choice of western blot commercial kit is paramount important than the use of particular interpretation criteria for the diagnosis of HIV-1.

This is an analysis of available chart data recorded by HIV counselors and physicians on patient adherence and CD4 count in 304 patients with HIV who were prescribed antiretroviral therapy (ART) in Chennai, India. HIV counselors had categorized the majority of patients' adherence as 'regular' (74.3%), with a significant minority being categorized as 'irregular' (17.8%), or 'recently missed some doses' (6.9%). Those categorized as 'irregular' had significantly lower CD4 counts than those classified as 'regular'. Adherence was not associated with any demographic variable; however, it was associated with current CD4 and with change in CD4 since initiation of ART. This association was significant over and above the effects of time on ART. The most common reason for non-adherence was cost (32%), followed by the inability to return for a refill (i.e., patients who were unable or refused to obtain medicines elsewhere) (7.5%). These data suggest that although most patients in this Indian cohort reported regular adherence to ART, a subset admitted to less than regular adherence to ART, and those who admitted to less than regular adherence had worse CD4 outcomes. These data do not support concerns about adherence as a reason to withhold ART in developing countries, nor do they support claims that patients in India who struggle with adherence would be unwilling or unable to admit to non-adherence to health care professionals.

We report the case of a 32 -year- old HIV-positive Indian male who presented with sixth nerve (bilateral), ninth, tenth and twelfth nerve palsies; cerebellar and posterior column involvement. CT scan showed gyriform enhancement in the right occipital lobe and nodular leptomeningeal enhancement in the left frontal lobe. Cytomegalovirus serology was positive and the patient was treated as presumed CMV. HIV can present with multiple cranial neuropathy and varied neurological involvement.

The clinical course of human immunodeficiency virus (HIV) disease and pattern of opportunistic infections varies from patient to patient and from country to country. The clinical profile of HIV disease in India includes a wide range of conditions like tuberculosis, cryptococcal meningitis, popular pruritic eruptions, and cytomegalovirus retinitis, among others. Tuberculosis is the most common opportunistic infection in Indian patients with HIV. Occurrence of various AIDS-associated illnesses determines disease progression. Mean survival time of Indian patients after diagnosis of HIV is 92 months. In this review, we discuss the clinical profile of HIV disease through an organ system-based approach. With the availability of antiretroviral therapy at lower cost, the clinical profile of HIV disease in India is now changing to include drug-related toxicities and immune reconstitution syndrome.

Human immunodeficiency virus (HIV) infection is a major health problem in India. The importance of oral lesions as clinical features of HIV infection and their gender specificity have been reported worldwide. However, there are very few reports on this aspect from the Indian subcontinent.The study population comprised 1000 consecutive HIV seropositive patients presenting to YRG CARE, a non-governmental organisation in Chennai, South India. The oral lesions were diagnosed based on clinical appearance using international criteria. Data were entered into a database and analysed using the SPSS package.The male-to-female ratio was 3.4:1, and 95% of the patients had acquired infection via heterosexual contact. Majority of the patients (84%) were in the 21- to 40-year-old age groups. Pulmonary tuberculosis (12%) was the most common systemic finding. Oral lesions were seen in 86.6% of the patients. Gingivitis (72.3%) and periodontitis (33.2%) were the most common lesions followed by oral pigmentation (26.3%), oral candidiasis (23.8%), angular cheilitis (7.9%), oral ulcers (3.3%), oral hairy leukoplakia (2.1%), oral submucous fibrosis (0.9%) and leukoplakia (1.5%). The prevalence of oral candidiasis, periodontitis and oral hairy leukoplakia was higher in males than in females.Oral lesions occur commonly in HIV infection. A comprehensive oral examination plays an important role not only in the management of the patients, but also in assessing the immune status and in their follow-up.

CD4+ T lymphocytes are currently the most common surrogate marker indicating immune status and disease progression with HIV infection. The cost of monitoring disease progression and response to therapy is still prohibitively expensive. Flow cytometry is the gold standard for the estimation of CD4+, but the high initial investment for this technology and expensive reagents makes it unaffordable for developing countries like India. We evaluated the Coulter cytosphere assay for quantifying CD4+ T lymphocytes in comparison with the standard method, flow cytometry, in 122 HIV-infected individuals. The correlation coefficient of the cytosphere assay compared with that of flow cytometry for CD4+ T lymphocytes was 0.97 (P0.0001), with a confidence interval of 0.95 to 0.98. The sensitivity, specificity, positive predictive value, and negative predictive value of the cytosphere assay in enumerating absolute CD4+ T-lymphocyte counts of less than 200/microL were 94.9%, 96.4%, 92.5%, and 97.6%, respectively. This is a simple inexpensive method and has a strong correlation with flow cytometry. Hence, the cytosphere assay can be an alternate to flow cytometry for the estimation of CD4+ T-lymphocyte counts, especially in resource-poor settings of developing countries, for monitoring HIV progression and response to therapy.

Despite advances in understanding HIV pathogenesis, the economic, social and legal constraints in India continue to make women particularly vulnerable to HIV infection.

Background: In most resource-constrained countries, CD4 cell count testing is prohibitively expensive for routine clinical use and is not widely available. As a result. physicians are often required to make decisions about opportunistic infection (OI) chemoprophylaxis without a laboratory evaluation of HIV stage and level of immunosuppression. Objectives: To evaluate the correlation of total lymphocyte count (TLC), an inexpensive and widely available parameter, to CD4 count. To determine a range of TLC cutoffs for the initiation of OI prophylaxis that is appropriate for resource-constrained settings. Methods: Spearman correlation between CD4 count and TLC was assessed in patients attending an HIV/AIDS clinic in South India. Positive predictive value (PPV), negative predictive value (NPV), and sensitivity and specificity of various TLC cutoffs were computed for CD4 count

Human immunovirus infection in India is rapidly increasing. Ocular lesions due to highly active antiretroviral therapy have been well recognized. Acquired immunodeficiency syndrome can affect all parts of the eye. However, posterior segment lesions are the most common and of these, Human immunodeficiency virus retinopathy and cytomegalovirus retinitis predominate. Often clinical examination can establish the diagnosis of many ocular lesions in acquired immunodeficiency syndrome; therefore, ophthalmologists need to be aware of the more common ones. Various drugs in different routes can used to treat cytomegalovirus retinitis. Highly active antiretroviral therapy has remarkably reduced systemic and ocular morbidity among acquired immunodeficiency syndrome patients. To facilitate care of these patients aseptic precautions for ophthalmic care personnel are now well established and therefore ophthalmologist should not hesitate to provide ophthalmic care to acquired immunodeficiency syndrome patients.

Objective To assess whether customised mobile phone reminders would improve adherence to therapy and thus decrease virological failure among HIV infected patients starting antiretroviral treatment (ART). Design Randomised controlled trial among HIV infected patients initiating antiretroviral treatment. Setting Three diverse healthcare delivery settings in south India: two ambulatory clinics within the Indian national programme and one private HIV healthcare clinic. Participants 631 HIV infected, ART naive, adult patients eligible to initiate first line ART were randomly assigned to mobile phone intervention (n=315) or standard care (n=316) and followed for 96 weeks.. Intervention The intervention consisted of customised, interactive, automated voice reminders, and a pictorial message that were sent weekly to the patients’ mobile phones for the duration of the study. Main outcome measures The primary outcome was time to virological failure (viral load >400 copies/mL on two consecutive measurements). Secondary outcomes included ART adherence measured by pill count, death rate, and attrition rate. Suboptimal adherence was defined as mean adherence

Importance Emerging data warrant the integration of biomedical and behavioral recommendations for human immunodeficiency virus (HIV) prevention in clinical care settings. Objective To provide current recommendations for the prevention of HIV infection in adults and adolescents for integration in clinical care settings. Data Sources, Study Selection, and Data Synthesis Data published or presented as abstracts at scientific conferences (past 17 years) were systematically searched and reviewed by the International Antiviral (formerly AIDS) Society—USA HIV Prevention Recommendations Panel. Panel members supplied additional relevant publications, reviewed available data, and formed recommendations by full-panel consensus. Results Testing for HIV is recommended at least once for all adults and adolescents, with repeated testing for those at increased risk of acquiring HIV. Clinicians should be alert to the possibility of acute HIV infection and promptly pursue diagnostic testing if suspected. At diagnosis of HIV, all individuals should be linked to care for timely initiation of antiretroviral therapy (ART). Support for adherence and retention in care, individualized risk assessment and counseling, assistance with partner notification, and periodic screening for common sexually transmitted infections (STIs) is recommended for HIV-infected individuals as part of care. In HIV-uninfected patients, those persons at high risk of HIV infection should be prioritized for delivery of interventions such as preexposure prophylaxis and individualized counseling on risk reduction. Daily emtricitabine/tenofovir disoproxil fumarate is recommended as preexposure prophylaxis for persons at high risk for HIV based on background incidence or recent diagnosis of incident STIs, use of injection drugs or shared needles, or recent use of nonoccupational postexposure prophylaxis; ongoing use of preexposure prophylaxis should be guided by regular risk assessment. For persons who inject drugs, harm reduction services should be provided (needle and syringe exchange programs, supervised injection, and available medically assisted therapies, including opioid agonists and antagonists); low-threshold detoxification and drug cessation programs should be made available. Postexposure prophylaxis is recommended for all persons who have sustained a mucosal or parenteral exposure to HIV from a known infected source and should be initiated as soon as possible. Conclusions and Relevance Data support the integration of biomedical and behavioral approaches for prevention of HIV infection in clinical care settings. A concerted effort to implement combination strategies for HIV prevention is needed to realize the goal of an AIDS-free generation.

Central retinal vein occlusion (CRVO) due to herpes zoster has rarely been reported. Varicella zoster virus is a common opportunistic infection in patients with AIDS. This case report is about a 40-year-old man with herpes zoster ophthalmicus and central retinal vein occlusion of the right eye who is HIV-positive. Although the lesion resolved following treatment with intravenous acyclovir and oral steroid, the patient subsequently developed florid disc neovascularization and vitreous hemorrhage. The paper highlights CRVO as the initial presentation in an AIDS patient with herpes zoster ophthalmicus.

A decrease in the number of new acquired immunodeficiency syndrome (AIDS) cases and AIDS--related deaths was seen in developed countries since 1996 due to the use of new combination of antiretroviral drugs. This retrospective study discusses the use of antiretroviral drugs in the treatment of people living with human immunodeficiency virus (HIV) in a developing country setting.A retrospective case note analysis was done of patients receiving antiretroviral therapy at YRG Centre for AIDS Research and Education between Aug. 1996 and Feb. 1999. Out of 936 persons with HIV treated at this centre, 6.1% of the patients were prescribed three groups of drugs: Group A was the combination of the reverse transcriptase inhibitors (nRTI) zidovudine 600 mg daily and lamivudine 300 mg daily, Group B was the combination of zidovudine 600 mg daily, lamivudine 300 mg daily with protease inhibitor (PI) ritonavir 1200 mg daily and Group C was the combination of zidovudine 600 mg daily and lamivudine 300 mg daily with indinavir 2400 mg daily. Twenty HIV positive pregnant women were given zidovudine 500 mg daily during the third trimester (Group D) to reduce the vertical transmission of HIV.The mean CD4 gain was 188.0 cells/micro litre in Group A, 118.8 cell/microlitre in Group B and 223.3 cells/microlitre in Group C with a mean duration of 4.3, 3.1 and 3.5 months respectively. Many patients stopped antiretroviral drugs due to high cost of therapy.Hence, physicians should prescribe antiretroviral drugs only after ensuring that the patients can afford and will comply with a longterm treatment. Prescribing guidelines should be available to those working in this field and should be adhered to so that emergence of resistant strains could be prevented.

Induced sputum samples were collected from 32 AIDS patients with respiratory ailments. Pneumcystis carinii was demonstrated in 9 out of 32 AIDS cases by Indirect Immunofluorescence technique (HF). Four cases were positive by all the three techniques namely Giemsa staining, Toluidine blue staining and IIF, three were positive by both toluidine blue and IIF, and two were positive only by IIF. Among other microbial pathogens, acid fast bacilli was demonstrated in all the P carinii positive cases and Candida albicans in 53% AIDS cases from the induced sputum sample.

A retrospective study was conducted on 134 HIV-infected females evaluated at an HIV/AIDS centre in south India to characterize their socio-demographics, HIV risk factors and initial clinical presentations. The mean age was 29 years; 81% were housewives; 95% were currently or previously married; 89% reported heterosexual sex as their only HIV risk factor; and 88% reported a history of monogamy. The majority were of reproductive age, thus the potential for vertical transmission of HIV and devastating impacts on families is alarming. Nearly half of these women initially presented asymptomatically implying that partner recruitment can enable early HIV detection. Single partner heterosexual sex with their husband was the only HIV risk factor for the majority of women. HIV prevention and intervention strategies need to focus on married, monogamous Indian women whose self-perception of HIV risk may be low, but whose risk is inextricably linked to the behaviour of their husbands.

This letter to the editor describes a study which investigated the profile of tuberculosis (TB) and the nature of drug resistance pattern among 176 HIV-positive subjects suspected of TB based on the clinical grounds attending a tertiary AIDS care center in Chennai South India. It states that anti-TB drug susceptibility testing should be performed for all patients who are culture positive for M. tuberculosis and concludes that there is a need for strengthening collaboration between TB and AIDS control programs to counteract the impact of HIV on TB.

We investigated 245 diarrheal stool specimens from HIV-positive subjects between January 2003 and December 2006 to determine the etiological role of coproparasites. Parasitic etiology was observed in 91 (37.1%) cases. Isospora belli (26.1%) was the most common parasite followed by Entameba histolytica/dispar (3.3%), Cryptosporidium spp. (2.9%), Giardia intestinalis (1.6%), and Strongyloides stercoralis (1.2%). Interesting trends of significant increase in the number of cases of I. belli and decline in Cryptosporidium spp. were observed during the study period.

Christian Laurent and colleagues in todays Lancet report on the efficacy and safety of a generic fixed-dose combination of nevirapine stavudine and lamivudine in HIV-1-infected adults in Cameroon. Highly active antiretroviral therapy (HAART) has led to dramatic reductions in HIV-related morbidity and mortality in the USA and in India. The use of HAART has led to cost effective public-health programmes in countries such as Brazil because there are now fewer episodes of illness and hospital admission. The cost of combination HIV-antiretroviral treatment has plummeted in the past 12 months such that HAART can now be bought for less than US $250 a year from Cipla and other generic companies. Cipla is a drug company in Mumbai India that launched the first generic antiretroviral drug zidovudine in 1994. Since then Cipla has launched ten different antiretroviral and fixed-dose combinations of antiretroviral drugs as single pills. Falling prices of therapy are enabling physician in the developing world to offer triple antiretroviral regimens to greater numbers of patients who desperately need the life-saving drugs. The safety tolerability and efficacy of genetic antiretroviral regiments for HIV-infected Indians has been shown. Also there were earlier reports that generic antiretroviral drugs were successfully used in HIV-infected patients in Africa. (excerpt)