Highlights from Recent Conferences -- Women And Pregnancy, Miscellaneous

Harvey S. Bartnof, MD

Candida Correlates with Viral Load

• The presence of Candida, the fungus that causes thrush and "yeast infections," correlates better with HIV viral load than with CD4 T-cell count.

Oral or vaginal candidiasis is often the first opportunistic infection among HIV infected women. The CD4 count at the first episode of candidiasis is usually only slightly decreased. Recurrence rates tend to increase as the CD4 count declines. Now, researchers from the University of Medicine and Dentistry in New Jersey have determined that oral or vaginal Candida infection correlates better with HIV viral than with CD4 count. In a prospective study of 24 HIV positive women, the researchers took swabbed samples from the mouth and vagina over 18 months. At baseline, all the women had a CD4 count of at least 200 cells/mm³.

The results showed no statistical difference in CD4 count between the women who had or acquired Candida infection (colonization) and those who did not. However, the former group had a significantly higher baseline HIV viral load (mean 13,850 copies/mL) than the latter group (mean 518 copies/mL). During the observation period, 58% of the women developed symptomatic vaginal candidiasis, while 21% developed oral candidiasis (thrush). The authors conclude that HIV viral load may be a better predictor than CD4 count of Candida infection. These results will help HIV positive women and their physicians to better understand the risks for Candida infection and disease.

Reboli, A.C. and others. Epidemiology of Candida carriage among HIV-infected women with CD4 count >= 200 cells/mm³. 36th IDSA. Abstract 323Fr.

HIV/AIDS Knowledge of New Mothers

• Knowledge of HIV/AIDS among a sample of new mothers in the U.S. is poor.

A disturbing report from the CDC described low rates of knowledge about HIV/AIDS among 1,362 new U.S. mothers in 1997. Participants were from North Carolina (753), Miami, Florida (200), Brooklyn, New York (201), and New Haven, Connecticut (208).

The new mothers were interviewed within one to two days after delivering their babies. Only 60% were aware that HIV could be transmitted by breast-feeding. Only 51% knew of a medication to help prevent HIV transmission to the newborn. Ninety-five percent knew that pregnancy could transmit HIV to the fetus. A total of 88% indicated that they had been offered an HIV test, and 75% of these women were tested. Women's HIV knowledge scores correlated with geographic location, income, race/ethnicity, education, and reported receipt of HIV/AIDS information and HIV testing during pregnancy.

The results indicate that HIV/AIDS education is lacking in some U.S. locations. When the federal government leaves choices about HIV/AIDS to individual states, the result is that many U.S. inhabitants are deficient in basic HIV knowledge.

Walter, E.B. and others. Knowledge, attitudes and beliefs about perinatal HIV and perinatal HIV testing among parturients sampled at four U.S. sites. 36th IDSA. Abstract 427.

TB Preventive Therapy During Pregnancy

• Researchers advocate preventive therapy for tuberculosis (TB) during pregnancy if a woman's PPD skin test is positive but no active disease is found.
• The current CDC recommendation is to wait until after delivery to begin TB preventive therapy.

Hamilton, C.D. and others. INH prophylaxis antepartum vs postpartum in women with a positive tuberculin skin test: results of a decision analysis model. 36th IDSA. Abstract 90.

Three-Day Regimen for Bacterial Vaginosis

• A three-day regimen of vaginal clindamycin cream or ovule is as effective as a seven-day vaginal cream regimen for bacterial vaginosis.
• Three studies of 1,642 HIV negative women were performed.
• Bacterial vaginosis increases the risk of sexual transmission of HIV, and can cause premature labor, which may increase HIV transmission to a newborn.

Robbins, J. and other. Shortened, 3-day course of clindamycin for bacterial vaginosis. 38th ICAAC. Abstract L-68a.

Lactoferrin in Breast Milk Inhibits HIV

• The human lactoferrin protein in breast milk inhibits HIV replication in vitro.

Viani, R.M. and others. Human and bovine lactoferrin inhibits human immunodeficiency virus type 1 replication in vitro. 38th ICAAC. Abstract I-46.

MISCELLANEOUS

Physician Experience Correlates with Following Treatment Guidelines

• Physicians with more HIV/AIDS patients are more likely to follow treatment guidelines.
• Physicians who specialize in infectious diseases or hematology-oncology are more likely to follow guidelines.
• Rural patients are less likely to be taking protease inhibitors than their urban counterparts.
• Physicians with the least HIV/AIDS experience provide most of the care for racial minorities and uninsured patients.

Is your physician following current HIV/AIDS guidelines? Whether or not he or she is may depend upon several critical factors. Researchers from the CDC and the University of California at San Francisco sent a survey to 2,052 U.S. physicians who had ever prescribed AZT or 3TC. While only 41% returned the survey, the results indicated two specific factors that consistently correlated with following current guidelines: higher number of HIV/AIDS patients and specialization in infectious diseases or hematology-oncology (the study of blood diseases and cancer). Having less than five HIV/AIDS patients -- and in some cases, less than 20 patients -- significantly correlated with not following guidelines. Physicians were asked about the use of HIV viral load tests, prescribing of antiretroviral therapy, prescribing prophylaxis for opportunistic infections, and screening for cervical cancer and past infection with hepatitis B virus and toxoplasmosis.

A second report on 4,045 surveyed physicians who prescribe antiretroviral therapy indicated that those with the least HIV/AIDS experience provide most of the care for racial/ethnic minorities and uninsured persons. Experience was measured by the number of HIV/AIDS patients treated.

In a separate but related study of 4,816 rural people with HIV, researchers from the University of Rochester found that 46% were not taking a protease inhibitor in 1996-1997. However, over 80% were taking other antiretroviral therapy. Rural patients were more often poor, less educated, unemployed, underinsured, Caucasian, and female.

These results and those of others indicate that HIV/AIDS experience, specific specialization, geographic location, and patient socioeconomic factors are all linked with physicians following current guidelines. This is turn will be linked with treatment outcome, including quality of life and survival.

Bartlett, J.G. and P. Volberding. HIV care delivery in the U.S. 36th IDSA. Abstract 8.

Brosgart, C.L. and others. Community patterns of care for HIV disease: clinical experience and medical specialty training make a difference. 36th IDSA. Abstract 399Fr.

Cohn, S.E. and others. Adults under care for HIV in rural areas of the United States. 36th IDSA. Abstract 400 Fr.

Transsexual People with HIV/AIDS

• Transsexual persons with HIV/AIDS have the same HIV/AIDS survival rates as non-transsexual persons with HIV/AIDS.
• Transsexual persons are on average diagnosed with AIDS at a later stage of immune suppression than non-transsexual people.
• Results were from a study of 15 persons from Detroit with "gender identity disorder."

Crane, L.R. and others. Outcomes analysis of HIV-infected transsexual patients (gender identity disorder): a retrospective cohort study. 38th ICAAC. Abstract O-8.

Harvey S. Bartnof, MD, has been a member of the Scientific Advisory Committee of the San Francisco AIDS Foundation since 1987.

DT 19990110
DOCN BE990117