|Year : 2007 | Volume
| Issue : 1 | Page : 48-50
Abstracts from current literature
Archana Sharma, Monika Singla, Ragini Ghiya
Department of Skin and VD, Medical College and SSG Hospital, Vadodara, India
OPD -1, Department of Skin and V.D., Govt. Medical College and SSG Hospital, Vadodara - 390 001
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Sharma A, Singla M, Ghiya R. Abstracts from current literature. Indian J Sex Transm Dis 2007;28:48-50
Women with HIV face crucial breastfeeding decisions
A mother living with human immunodeficiency virus (HIV) faces a difficult decision - whether to breastfeed, in order to give her infant important nutrients and protection from potentially deadly diseases; or not to breastfeed, to avoid the risk of transmitting HIV through breast milk.
HIV transmission through breast milk is more likely among mothers with higher levels of HIV in breast milk/maternal plasma, low CD 4 counts, primary HIV infection, mastitis, breast abscess and nipple lesions. Oral thrush in infants also increases the risk. Transmission through breastfeeding is estimated to account for one-fourth to one-half of infant HIV infections. Among 100 children born to mothers with HIV who don't receive antiretroviral treatment (ART), an estimated 15-25 children would become infected with HIV during gestation and delivery. If mothers with HIV were to breastfeed their infant up to 6 months of age, an additional 5-10 of these 100 children would become infected. On an average, 16% of babies would become infected if breastfeeding were to continue for 2 years. Infants who are mixed-fed are four times more likely to have acquired HIV at 6 months than those who are exclusively breastfed. It is thought that other foods disturb the intestinal lining of infants in the first three months of life, allowing HIV to pass more easily into the blood stream. HIV transmission through breastfeeding can be reduced through exclusive and shorter breastfeeding for the first few months of life and stopping breastfeeding if replacement feeding can meet five essential criteria - affordable, feasible, acceptable, sustainable and safe (AFASS). What should providers and mothers do? Breast milk should be expressed either manually or with a breast pump and can be either flash heated or pasteurized, followed by cooling to kill HIV and the cells that carry it. Wet nursing should be considered only when the prospective wet nurse tests HIV negative and remains so during the feeding period. Liquid commercial formulas based on modified animal milk or soy protein lack essential fatty acids, hormones, immune cells and other factors present in breast milk. Home-modified animal milk is not fit for infants less than 6 months of age unless it is properly modified. Currently, 10% of pregnant women are offered ART. ART can reduce the risk of HIV infection in infants. A number of clinical trials are underway or planned to assess whether these drugs can reduce HIV transmission through breastfeeding beyond the first few weeks postpartum. Studies suggest that addition of small amount of Sodium Dodecyl Sulfate (SDS) to breast milk kills all HIV without harming breast milk.
Better breast feeding, healthier lives. Population reports info, series L, no.14. issues in world health, July-August 2006.
Chronic neuropsychiatric symptoms in patients on long-term efavirenz
Efavirenz is one of the most widely used antiretroviral drugs. Australian researchers have recently conducted a cross-sectional case-controlled study comparing patients treated with EFV for at least 6 months with matched control group (Rihs et al . HIV Med 2006; 7: 544-8). Self-administered standardized questionnaires including the Depression Anxiety Stress Scale (DASS), the Cognitive Failure Questionnaires (CFQ) and a questionnaire on unusual dreams, insomnia, fatigue, dizziness, depersonalization and derealization were administered to study patients. Data for 32 matched pairs were analyzed. Overall, significantly higher total stress scores were found in the EFV group compared to controls ( P = 0.008). Of subjects with elevated stress scores, 19% also reported severe to extremely severe symptoms ( P = 0.014), including increased difficulty in relaxing; being more irritable, impatient, agitated; and getting easily upset.
On other hand, 19% of patients treated with EFV also reported severe levels of anxiety as assessed by the DASS scale compared to controls ( P = 0.059). This patient group also reported a higher rate of unusual dreams ( P = 0.049). No significant differences between groups were found for measures of cognitive impairment, fatigue, dizziness, derealization or depersonalization.
In conclusion, patients exposed to EFV for long periods experience higher levels of stress and anxiety, as well as higher rate of unusual dreams, than patients not treated with EFV. These differences may reflect persisting central nervous system side effects of the drug.
Lucia Gallego. Hot News. AIDS reviews 2007;9:61-63
Systemic review of the safety of Trimethoprim- Sulfamethoxazole for prophylaxis in HIV-infected pregnant women: implications for resource -limited settings
Daily prophylaxis with Trimethoprim- Sulfamethoxazole (TMP-SMZ) significantly decreases morbidity and mortality among people living with HIV. Some clinicians are reluctant to use TMP-SMZ in pregnant and breastfeeding HIV-infected women because of concerns about the possible teratogenicity when used in the first trimester and about its potential to induce hyperbilirubinemia near term and during early breastfeeding.
The authors systemically reviewed evidence regarding toxicity of TMP-SMZ prophylaxis in pregnant and breastfeeding women to guide practice in resource-limited settings. They identified relevant literature by searching Pub Med and MEDLINE via OVID, Embase and Science Citation Index for data on hyperbilirubinemia, kernicterus and teratogenicity associated with administration of sulfonamides and TMP-SMZ through July 2005. They also reviewed the reference list of identified articles.
Most studies demonstrated that TMP-SMZ was not associated with hyperbilirubinemia when administered to mothers during pregnancy and breastfeeding. No cases of kernicterus were reported in neonates after maternal ingestion of sulfonamides. There is mixed evidence linking ingestion of TMP-SMZ and other sulfonamides in early pregnancy to elevated risk of oral clefts, neural tube defects and cardiovascular and urinary tract abnormalities, although some sources found that supplementation with folic acid might ameliorate this potential risk. Existing guidelines recommend that HIV-infected pregnant women receive prophylaxis, but they differ with regards to stage of disease at which to initiate treatment, need for CD4 + T-Lymphocyte testing and prophylaxis during the first trimester. Existing data indicate that the risk of serious injury to neonates from maternal use of daily TMP-SMZ prophylaxis during pregnancy and breastfeeding is small. Given the substantial benefits of TMP-SMZ prophylaxis for HIV-infected women living in resource-limited settings, this review indicates that it is safe to abide by the WHO guidelines recommending TMP-SMZ prophylaxis for HIV-infected pregnant women.
Fatu Forna, Michelle McConnell, Florence N. Kitabire et al. Systemic review of the safety of Trimethoprim- Sulfamethoxazole for prophylaxis in HIV- Infected Pregnant Women: Implications for Resource -Limited Setting. AIDS Reviews 2006;8:24-36.
Randomized controlled trial of an adjuvanted Human Papillomavirus (HPV) type 6 L2E7 vaccine: Infection of external, anogenital warts with multiple HPV types and failure of therapeutic vaccination
Cellular immunity is involved in spontaneous clearance of anogenital warts most typically caused by human papillomavirus (HPV) type 6 or 11, supporting the concept of therapeutic vaccination. A therapeutic vaccine composed of HPV-6 L2E7 fusion protein and AS02A adjuvant was evaluated in conjunction with conventional therapies in subjects with anogenital warts.
A total of 457 subjects with anogenital warts were screened, of which 320 with HPV-6 and/or HPV-11 infection were enrolled into two double-blind, placebo-controlled sub-studies. Three doses of vaccine or placebo were administered along with either ablative therapy or podophyllotoxin.
Although a positive trend towards clearance was seen in patients infected with only HPV-6, in neither sub-study did the vaccine significantly increase the efficacy of conventional therapies, despite induction of adequate immune responses. Extensive HPV typing by polymerase chain reaction demonstrated that a majority of screened subjects (73.7%) were infected with HPV-6 and/or HPV 11 and that a large proportion of subjects (40.1%) were infected with multiple HPV types. HPV types that put subjects at high risk of development of cervical cancer were detected in 39.8% of subjects.
Infection with multiple HPV types, including high-risk types, is common in anogenital wart disease. Therapeutic vaccination failed to increase the efficacy of conventional therapies.
Pierre Vandepapeliere, Renzo Barrasso, Chris JLM Meijer et al. L2E7 Therapeutic Vaccination for HPV. JID 2005:192. 2099-2106.
The NEFA study: results at 3 years
The concept of simplification emerged as a need for adherent HIV-infected patients receiving successful complex or inconvenient antiretroviral regimens, and it has now been incorporated into the updated recommendations for the use of antiretroviral therapy. The NEFA (Nevirapine, Efavirenz and Abacavir) study was a multicenter randomized controlled open-label clinical trial initially designed for 1 year of follow-up (Martinez et al . N Engl J Med 2003;349:1036-46), although follow-up was extended up to 3 years following recommendations from the European Health Authorities in studies of maintenance therapy with simplified regimen in patients showing adequate virologic control. Eligible patients were HIV-1-infected adults who were receiving triple antiretroviral therapy consisting of at least one protease inhibitor (PI) plus two nucleoside reverse transcriptase inhibitors (NRTI), who had plasma HIV RNA <200 copies/ml for at least the previous 6 months and who wished to change the PI component of their regimen. Patients were randomly assigned to receive Nevirapine, Efavirenz or Abacavir instead of the PI used in their current antiretroviral regimen, while their NRTI remained unchanged.
The response rates did not differ significantly between Nevirapine and Efavirenz after 1 year of follow-up, and these results were maintained after 3 years of follow-up. At 3 years, the Kaplan Meier estimates to reach a protocol-defined end point in the Nevirapine (n = 155), Efavirenz (n = 156) and Abacavir (n = 149) arms were 33, 46 and 40% respectively in the intent-to-treat analysis (generalized long-rank test, P = 0.068).
Remarkable differences were also seen in the time to development of adverse effects. Side effects leading to discontinuation of Nevirapine and Abacavir were concentrated almost exclusively in the first weeks of the study, whereas minor but persistent neuropsychiatric adverse effects led to late discontinuation of Efavirenz during the entire study follow-up (Martinez et al . AIDS 2007;21:367-9).
In summary, simplification of protease inhibitor-containing Highly active antiretroviral treatment in patients with sustained virologic response had a higher probability of maintaining the suppression of viral replication after 3 years of follow-up when Nevirapine or Efavirenz were substituted for PI as compared with Abacavir. However, in contrast with patients on Nevirapine who had excellent long-term tolerability, patients on Efavirenz showed a low but continuous discontinuation of the study drug due to minor but persistent neuropsychiatric adverse effects.
Esteban Martinez. The NEFA study: Results at three years. AIDS Reviews 2007;9:61-3.