Search

The prevalence of drug resistance was determined among 64 HIV-infected Thai patients who were failed while receiving nonnucleoside reverse transcriptase inhibitor (NNRTI)-based regimens. Eighty-nine percent of patients had 1 or [...]

Background: Matching supply side of the Internal Medicine (IM) subspecialists to the demand for complex medical care at referral medical centers would lead to more efficient health system management and ultimately optimal clinical outcome. The second decade of the universal health coverage policy in Thailand has raised the awareness on how to reach equitable utilization goals of good quality medical services, while barriers of accession have been removed. More accurate evidence-based human resource planning is timely needed. Objective: To estimate the number of the ten subspecialists in internal medicine (neurologist, cardiologist, endocrinologist, gastroenterologist and hepatologist, nephrologist, hematologist, oncologist, rheumatologist, pulmonologist, and infectious disease specialist) needed for complex medical care based on the workload in the year 2013. Material and Method: The present study applied a needs assessment model with evidence-based approach. Claimed data of inpatients in the year 2013 from the three government insurance schemes (the Civil Servant Medical Benefit, the Social Security and the Universal Health Coverage schemes), and out-patient data from Universal Coverage System were used to estimate demand for subspecialists. The Human Resource Working Group of the Royal College of Physicians of Thailand agreed on the conceptual framework to estimate the need for ten subspecialists based on clinical activities of outpatient consultations, inpatient ward rounds and non-operating room procedures on medical cases of respective diagnosis related group with severe and catastrophic comorbidities and complications by the Thai-DRG version 5. Representatives from the Associations of IM subspecialties approved the lists of ICD-10 diagnosis and ICD-9-CM procedure codes specific to each subspecialist care and proposed assumptions on rates of consultations from other specialists. Surveys were done to subspecialists in 6 major provincial clusters and representatives from IM subspecialty Associations asking time spent on main activities of patient care. The number of full-time-equivalent (FTE) subspecialists needed was calculated by multiplying the clinical workloads measured in minutes spent for each activity (ward round, ward work, inpatient and outpatient consultations) to get the total time needed, then divided by the available time for clinical activity of one subspecialist. Results: From 5.9 million inpatient discharges in the year 2013, primary responsibility of patients in respective severe and catastrophic DRGs related to specific subspecialist workloads were summed up for teaching hospitals and regional hospitals ranging from as lowest the 2,849 cases for rheumatology to the highest 24,610 cases for gastroenterology and hepatology. The number of inpatient non-operating room procedures by ICD-9-CM as listed by IM subspecialty Associations ranged from 8 times for endocrinologists to 22,927 times for cardiologists for the whole year. Of ten subspecialists, the estimated numbers of cardiologist, nephrologist, neurologist, gastroenterologist and hepatologist, endocrinologist, oncologist, rheumatologist, hematologist, pulmonologist and infectious disease subspecialist needed at teaching and regional hospitals were 516, 241; 345, 144; 312, 143; 195, 124; 189, 45; 137, 170; 90, 47; 96, 111; 203, 87 and; 129, 44 respectively according to the workload recorded in the year 2013. The forecast FTE found the overall gap of discrepancy at 7 percent. If the distributions of these subspecialists in public and private hospitals were taken into account, the gap of discrepancy in public hospitals increased to 47 percent. Conclusion: The demand-based forecast for the number of subspecialist needed was made possible with assumptions on conceptual framework for case selection, the rates of consultation and time-spent related to activities of patient care. The estimated numbers of subspecialists were anticipated far from optimum since the workload in the year 2013 was derived as a consequence of pre-existing suboptimal infrastructure of healthcare system. In addition, the deficit of subspecialists may increase in the near future when highly efficient, non- or mildly invasive, time-consuming procedures of acute illness increase. Sustainable matching demand and supply of human resource for health needed further validations of these assumptions. [ABSTRACT FROM AUTHOR]

: Using a randomized controlled trial, Marc Lallemant and colleagues ask if a CD4-based monitoring and treatment switching strategy provides a similar clinical outcome compared to the standard viral load-based strategy for adults with HIV in Thailand. Please see later in the article for the Editors' Summary [ABSTRACT FROM AUTHOR]

Background: Use of several antiretrovirals (ARVs) has been shown to be associated with a higher risk of diabetes in HIV-infected adults. We estimated the incidence of new-onset diabetes and assessed the association between individual ARVs and ARV combinations, and diabetes in a large cohort in Thailand., Methods: We selected all HIV-1-infected, nondiabetic, antiretroviral-naive adults enrolled in the Program for HIV Prevention and Treatment cohort (NCT00433030) between January 2000 and December 2011. Diabetes was defined as confirmed fasting plasma glucose ≥ 126 mg/dL or random plasma glucose ≥ 2 00 mg/dL. Incidence was the number of cases divided by the total number of person-years of follow-up. Association between ARVs and ARV combinations, and new-onset diabetes was assessed using Cox proportional hazards models., Results: Overall, 1594 HIV-infected patients (76% female) were included. Median age at antiretroviral therapy initiation was 32.5 years. The incidence rate of diabetes was 5.0 per 1000 person-years of follow-up (95% confidence interval: 3.8 to 6.6) (53 cases). In analyses adjusted for potential confounders, exposure to stavudine + didanosine [adjusted hazard ratio (aHR) = 3.9; P = 0.001] and cumulative exposure ≥ 1 year to zidovudine (aHR = 2.3 vs. no exposure; P = 0.009) were associated with a higher risk of diabetes. Conversely, cumulative exposure ≥ 1 year to tenofovir (aHR = 0.4 vs. no exposure; P = 0.02) and emtricitabine (aHR = 0.4 vs. no exposure; P = 0.03) were associated with a lower risk., Conclusions: The incidence of diabetes in this predominantly female, young, lean population was relatively low. Although stavudine and didanosine have now been phased out in most antiretroviral therapy programs, our analysis suggests a higher risk of diabetes with zidovudine, frequently prescribed today in resource-limited settings.

Ergotism is a toxic condition resulting from overexposure to the ergot compounds produced by various fungi of the genus Claviceps. Traditionally, such exposure was due to ingestion of infected grains, but long-term or excessive use of medications containing ergot derivatives or drug-drug interactions between these medications can result in ergotism. Ergotamine, typically used to treat migraine, has less than 5% bioavailability due to extensive first-pass metabolism by cytochrome P450 3A4 (CYP3A4). Concurrent intake of ergotamine and strong CYP3A4 inhibitors, such as the HIV protease inhibitors (PIs), can lead to clinical ergotism. A total of 13 cases of clinical ergotism in HIV-infected patients has been published since 1997 (most recently reviewed by Frohlich et al).

This retrospective cohort study was conducted at Chon Buri Hospital, Thailand, to determine the long term outcomes of patients taking Nevirapine (NVP) containing antiretroviral therapy (ART). Patients taken NVP at least 5 years were included. Two hundred eighty-five patients met inclusion criteria and were included in the study. The median age of patients was 35 years; the median baseline CD4 was 66 cells/mm3 and the median follow-up was 7 years. Ninety-two point four percent and 90.2% of patients achieved virological success at year 5 and year 7, respectively. The median rise in CD4 count from baseline to year 5 was 354 cells/mm3 (IQR 235.5-487 cells/mm3) and at year 7 was 387 cells/mm3 (IQR 272-557 cells/mm3). Thirty-eight point eight percent of patients had a CD4 count > or = 500 cells/mm3 at year 5 and 41.6% at year 7. Rash/hypersensitivity occurred in 2 patients after 5 years and was transient. Elevated liver enzymes occurred in 5 patients after 5 years. NVP-containing ART yielded high virological-success rates. Long-term immunological response, safety and durability were also high.

Background: The impact of pregnancy on efavirenz (EFV) pharmacokinetics is unknown., Methods: International Maternal Pediatric Adolescent AIDS Clinical Trials P1026s is an on-going, prospective, nonblinded study of antiretroviral pharmacokinetics in HIV-infected pregnant women that included a cohort receiving 600 mg EFV once daily as part of combination antiretroviral therapy. Intensive steady-state 24-hour blood sampling was performed during the third trimester and at 6-12 weeks postpartum. Maternal and umbilical cord blood samples were drawn at delivery. Pharmacokinetics targets were the estimated 10th percentile EFV area under the curve (AUC) in nonpregnant historical controls (40.0 mcg·hr(-1)·mL(-1)) and a trough concentration of 1 mcg/mL., Results: Twenty-five women were enrolled during the third trimester: median (range) age was 29.3 (18.9-42.9) years, weight 69.0 (40-130) kg, and gestational age 32.9 (30.1-38.7) weeks. Median (range) EFV AUC(0-24), C(max), and C(24 hours) were 55.4 mcg·hr(-1)·mL(-1) (13.5-220.3), 5.4 mcg/mL (1.9-12.2), and 1.6 mcg/mL (0.23-8.13), respectively. EFV AUC and C(max) did not differ during pregnancy and postpartum but C(24 hours) was lower during the third trimester (1.6 vs. 2.1 mcg/mL, P = 0.01). During the third trimester, 5 of 25 (20%) women had an EFV AUC below the target and 3 of 25 (12%) had a trough concentration below 1 mcg/mL. EFV cord blood/maternal concentration ratio was 0.49 (0.37-0.74). All women had a HIV-1 RNA viral load less than 400 copies per milliliter at delivery and 19 (76%) had a viral load below 50 copies per milliliter. One child was perinatally HIV infected. Three women were exposed to EFV throughout the first 6 weeks of pregnancy. EFV was well tolerated, and among the 25 infants, no congenital anomalies or newborn complications were reported., Conclusions: Changes in EFV pharmacokinetics during pregnancy compared with postpartum are not sufficiently large enough to warrant a dose adjustment during pregnancy.

Histoplasmosis and penicilliosis are fungal infections with similar clinical presentation and laboratory findings that were reported mainly in the era prior to highly active antiretroviral therapy. We conducted a retrospective review at two hospitals in Central Thailand of the medical records of HIV-positive patients with microbiologic evidence of histoplasmosis or penicilliosis between January 2003 to September 2007 when antiretrovirals became widely available in Thailand. Fifty patients met inclusion criteria; 36 had histoplasmosis, and 14 had penicilliosis. Symptoms and laboratory findings on presentation were similar between the two infections except for a greater incidence of tachypnea and neutropenia among patients with histoplasmosis (both p < 0.05). For histoplasmosis, blood culture had a significantly lower yield for detecting infection compared to tissue microscopic examination highlighting the importance of obtaining tissue for diagnosis (p < 0.05).

Background: Data informing the use of boosted protease inhibitor (PI) monotherapy as second-line treatment are limited. There are also no randomized trials addressing treatment options after failing first-line non-nucleoside reverse transcriptase inhibitor (NNRTI)-regimens., Methods: HIV-infected subjects ≥18 years, with HIV RNA≥1,000 copies/ml while using NNRTI plus 2 NRTIs, and naive to PIs were randomized to lopinavir/ritonavir (LPV/r) 400/100 mg twice daily monotherapy (mono-LPV/r) or tenofovir disoproxil fumarate (TDF) once daily plus lamivudine (3TC) twice daily plus LPV/r 400/100 mg twice daily (TDF/3TC/LPV/r) at nine sites in Thailand. The primary outcome was time-weighted area under curve (TWAUC) change in HIV RNA over 48 weeks. The a priori hypothesis was that the mono-LPV/r arm would be considered non-inferior if the upper 95% confidence limit in TWAUC mean difference was ≤0.5 log(10) copies/ml., Results: The intention-to-treat (ITT) population comprised 195 patients (mono-LPV/r n=98 and TDF/3TC/LPV/r n=97): male 58%, baseline mean (sd) age of 38 (7) years, CD4(+) T-cell count of 204 (135) cells/mm(3) and HIV RNA of 4.1 (0.6) log(10) copies/ml. The majority had HIV-1 recombinant CRF01&#95;AE infection, and thymidine analogue mutation (TAM)-2 was 3× more common than TAM-1. At 48 weeks, the difference in TWAUC HIV RNA between arms was 0.15 (95% CI -0.04, 0.33) log(10) copies/ml, consistent with our definition of non-inferiority. However, the proportion with HIV RNA<50 copies/ml was significantly lower in the mono-LPV/r arm: 61% versus 83% (ITT, P<0.01). Baseline HIV RNA≥5 log(10) copies/ml (P<0.001) and mono-LPV/r use (P=0.003) were predictors of virological failure. Baseline genotypic sensitivity scores ≥2 and TAM-2 were associated with better virological control in subjects treated with the TDF-containing regimen., Conclusions: In PI-naive patients failing NNRTI-based first-line HAART, mono-LPV/r had a significantly lower proportion of patients with HIV RNA<50 copies/ml compared to the TDF/3TC/LPV/r treatment. Thus, mono-LPV/r should not be recommended as a second-line option.

Background: More than 100,000 patients have been treated, since the implementation of the National Universal Coverage for antiretroviral therapy (ART) in Thailand Although there are several comprehensive guidelines available internationally, there is a need to have guidelines that can be implemented in Thailand., Material and Method: The guidelines were developed by a panel of 17 members who are the experts on HIV research and/or HIV patient care and appointed without incentive by the Thai AIDS Society (TAS). The recommendations were based on evidences from the published studies and availability of antiretroviral agents. Published studies that are relevant and applicable to Thailand in particular have been taken into consideration., Results: The recommendations include: when to start ART; what to start; how to monitor the therapy; adverse effects and its management; diagnosis of treatment failure; and antiretroviral treatment options in patients with treatment failure. ART in special circumstances, i.e., patients with co-infection of tuberculosis or hepatitis B virus, is also included Appropriate level of CD4+ T-cell count to start ART among Thai patients has been considered carefully. The authors recommend to start ART at CD4+ T-cell count < 200 cells/mm3., Conclusion: ART should be initiated in adults and adolescents HIV-1 infected patients with a history of HIV-related illness or AIDS or with a CD4+ T-cell count <200 cells/mm3. For treatment-naive patients, the preferred initial therapy is a non-nucleoside reverse transcriptase inhibitor (NNRTI)-based regimen. CD4' T-cell count and viral load should be monitored for at least twice and once a year, respectively. Proper management of antiretroviral-related toxicity and enhancement of adherence are crucial for the long-term success of ART.

A descriptive, combined retrospective and prospective study was conducted at the Anonymous Clinic, Chon Buri Hospital, Chon Buri Province, Thailand from November 10, 2003 to January 4, 2004. A total of 83 adult HIV-treatment-naïve patients undergoing treatment with GPO-VIR (stavudine, lamivudine, and nevirapine) for at least one year were studied. The objectives of the study were to assess the efficacy of GPO-VIR by evaluating body weight changes, CD4 T-cell count changes, the occurrence of opportunistic infections, and long-term side effects, such as lipodystrophy, during treatment. Of 83 studied patients, approximately half (52.3%) of them had a body weight increase > 10% of pre-treatment body weight after 12 months treatment. After taking GPO-VIR, CD4 T-cell counts increased rapidly, by a median of 78 x 10(6) cells/l during the first three months. 39.5% of the patients attained median CD4 counts > 200 x 10(6) cells/I, and 11.6% achieved > 500 x 10(6) cells/l after 2 years of treatment. The occurrence of opportunistic infections was significantly lower after treatment with GPO-VIR (p = 0.001). Subjective assessment of lipodystrophy by physicians and patients showed that 16.8% had symptoms of lipodystrophy within 2 years of GPO-VIR treatment. There was a significant association between older age group (40-49 years) and occurrence of lipodystrophy (p = 0.043). GPO-VIR is an inexpensive and effective antiretroviral drug regimen for initiating treatment of naïve patients, but careful assessment for lipodystrophy is necessary, especially after one year of treatment.