Bridging the Gap: Conference Record [Abstract book, International Conference on AIDS (12th: 1998: Geneva, Switzerland)]

12th World AIDS Conference

Abstracts 22165-22169 295

Design: Retrospective study.
Methods: Between 1996-1998 we studies the dynamics of the coinfection
HIV - M. tuberculosis evolution upon 46 children with different stages of HIV
- infection (based on CDC 1993 norms). The diagnosis of TB was based on
tuberculin skin test, chest radiography and epidemiological investigation. The
ELISA immunoenzymatical method (TAT test) was valuable in a first phase of TB
diagnosis.
Results: After 18 months of immuno-clinical and radiological evaluation and
appliance of antituberculosis therapy on the initial cased with TB (15 children), also
appliance of preventive therapy on the close contacts we obtained the following
results - 2 death among the initial cases which received antituberculosis therapy
(one with disseminated form of TB, one with pulmonary TB and Pneumocistosis);
6 new cases with active TB among close contacts which received prevention
therapy; re-activation of pulmonary TB in 3 treated cases.
Conclusion: Coinfection with M. tuberculosis in HIV-infected children represents a high risk factor in aggravating the immunoclinical status, in the appearance
of the other serious opportunistic diseases as well as in the increase of death
rate.
22165 Broncho-pulmonary tuberculosis (TB) associated with
the HIV infection
Alla D. Vovk, V.F. Poddubny, S.N. Antonyak. Spusk Protasov Jar 4 Intitute
Epidem. & Infec. Diseases Kiyv 252038, Ukraine
Objectives: To compare the frequency of broncho-pulmonary tuberculosis in
HIV-infected patients and other population.
Design: Prospective, controlled investigation.
Methods: Clinical studies of HIV-associated conditions.
Results: Broncho-pulmonary conditions including also TB became the most
common and dangerous HIV-associated diseases. The broncho-pulmonary TB
frequency in HIV-infected patients in Ukraine (2548.6 per 100,000 of HIV-infected
persons) is 74 times higher comparing to the rest of Ukrainian population. Among
390 AIDS patients investigated the TB infection was found in 124 ones. All the
pulmonary symptoms in HIV-infected patients are usually non-specific, prolonged
fever, cough, and weight loss being the most common ones. X-ray investigations
showed infiltrative changes both in upper and lower respiratory tract as well as the
marked microfocal dissemination on the background of clear contours. A drastic
decrease of CD+4 lymphocytes is registered (from 200 to 23//1l).
Conclusion: HIV-infected and AIDS patients belong to a group with a very high
TB frequency.
[22166 Decreasing incidence of mycobacterial diseases in HIV+
patients
Stefan Mauss, E. Wolf, E. Munich, R. Pscucci, H. Jaeger. KIS, Curatorium for
Immunedeficiency Mozartstr 3, D-80336 Munich, Germany
Objectives: To assess the influence of the introduction of antiretroviral combination therapy on the incidence of atypical mycobacterial diseases and tuberculosis
(Tb).
Design + Methods: Retrospective analysis of the 6 months incidence of microbiologically proven disease with atypical mycobacteria or Tb in HIV+ patients
of a HIV outpatient clinic.
Results:

S22167 Underuse of primary prophylaxis for Mycobacterium
avium complex (MAC) in a representative sample of
HIV-infected patients in care in the USA: Who is missing
out?
Steven Asch1, J.A. McCutchan2, S. Bozzette2, A. Gifford2, C. Winslow2,
M. Shapiro3. 111301 Wilshire Blvd, Los Angeles CA 90073; 2UCSD San Diego
CA; 3UCLA Los Angeles CA, USA
Background: Primary prophylaxis for MAC is recommended for HIV infected
patients with CD4 < 50, but the proportion of eligible patients receiving treatment
is unknown.
Methods: The HCSUS cohort is a nationally representative probability sample
of persons in care for HIV. This analysis uses the final baseline sample of 2865
respondents and weights to adjust for sampling, multiplicity and non-response.
Linearization methods were used to correct for the weights and multistage sampling design in both descriptive and inferential statistics.
Results: 19% of patients had no history of MAC and a lowest ever CD4 <
50. Only 41% of these patients with lowest ever CD4 < 50 reported taking any
MAC drug in preceding 6 months. Patients aged 25-40 (38%), and 50+ (36%)
were less likely to receive needed prophylaxis than those 18-25 (59%) or 40-50
(51%, p =.03). Fewer African Americans (34%) and Latinos (26%) received
this recommended treatment than whites (49%, p <.001). Poorer people received less recommended treatment: patients with no reported income-14%, $US
1-$9,999-36%, $US10,000-39,999 - 41%, and >$US40,000 - 55% (p =.008);
as did patients without a college education (34% vs. 49%, p <.001). Patients
who reported never having had sex with men (31% vs. 45%,p =.003) or abusing
intravenous drugs (33% vs. 43%, p =.06) also received such treatment less often
than the remainder those represented by the sample. Patients without insurance
(27%) and those with Medicaid (40%) were also less likely to receive primary
prophylaxis than patients with private insurance (50%, p =.01). Regional variation
in underuse also occurred, with patients in the Northeast least likely to receive
prophylaxis (24%) and patients in the West most likely (53%, p <.001).
Conclusions: We conclude that there is substantial underuse of MAC chemoprophylactic regimens, particularly among impoverished, underinsured or poorly
educated ethnic minorities. Multivariate modeling will allow analysis of the independent contribution of each of these factors. Our results support provider and
patient educational interventions and other policies that improve access to MAC
prophylactic drugs.
22168 Disseminated Mycobacterium avium complex infection in
Madrid: Low incidence in a prospective study in the
HAART era
Oscar Serrano, J.M. Peha, J.R. Arribas, J. Gonzales, F. Arnalich, A. Gonzales,
J.J. Vasquez. Unidad Vih. Hospital La Paz. Paseo De La Castellana, 261 28046,
Madrid, Spain
Objective: To determine the current rates of disseminated MAC infection.
Setting: A university hospital in an area with a high prevalence of tuberculosis.
Methods: Begining in November 1996 after obtaining informed consent, all
HIV-infected patients with CD4 cell counts <100/mm3 and initial negative MAC
blood cultures plus no other exclusion criteria were followed prospectively. Patients were screened every 3 months with blood cultures for MAC, CD4 cell counts
and MV viremia.
Results: In January 1998, 150 patients have been included, 30% of them
had a history of tuberculosis infection or disease. The median CD4 cell counts
at entry was 45/mm3. 78% of the patients received HAART. The median CD4
cell counts at 6 months was 102/mm3 and at 9 months was 134/mm3. In a 897
patient-months follow-up we did 449 blood cultures. The total incidence density
of MAC bacteremia was 2.23%. patient- months and the actuarial incidence at
12 months was 2.66%. The incidence density in those patients whose CD4 cell
count didn't increase above 100/mm3, was 6.3%. patient-months, an actuarial
incidence at 12 months of 7.7%.
Conclusions: As the preliminary results of this ongoing study show that the
current rates of incidence of disseminated MAC infection are rather low, the
recommendations of prophylaxis for MAC should be re-examinated in our area.
S22169 Clinical correlation of antimicrobial susceptibilities for
Mycobacterium avium complex (MAC) isolates from AIDS
patients with disseminated MAC disease
Ross G. Hewitt1, G.D. Papad Onatos2, C.B. Hsiao2, M.J. Shelton2,
N.L. Corriere3, W.D. Amsterdam3. 1462 Grider St Buffalo, New York 14215-3021;
2Suny at Buffalo Buffalo NY; 3Erie County Medical Center Buffalo NY, USA
Objective: to correlate clinically the antimicrobial susceptibilities of MAC isolates
from AIDS patients (pts) with disseminated MAC disease (DMAC)
Methods: from 12/92 to 12/97, susceptibility testing for amikacin (AM),
ciprofloxacin (Cl), clarithromycin (CR), clofazimine (CF), ethambutol (ET) and
rifabutin (RF) was performed on blood and bone marrow MAC isolates. Growth

in the presence of a standard concentration was reported to physicians as resistant. Response to anti-MAC treatment was assessed by chart review and the
presence of follow-up cultures. Clinical circumstances were: breakthrough on
anti-MAC prophylaxis (B), failure of known MAC treatment (F), clinical relapse
(RL), and new infection on no prophylaxis (NI). Responses were: resolution (R),
treatment failure (TF), or death (D).

Atyp. mycobact.
Median CD4+// I
Median HIV viral
Load (kEq/ml) Tb
Median CD4+//p
Median HIV viral
Load (kEq/ml)
pts CD4+ - 50/p/I

1/94
(n=589)
7
(1.2%)
20
10
(2.0%)
55

11/94 1/95 11/95 1/96
(n=576) (n=477) (n=595) (n=626)
9 10 7 5
(1.6%) (1.7%) (1.1%) (0.7%)
20 15 15 10
- 317 617 83
13 1 0 2
(2.1%) (0.2%) (0.3%)
118 340 - 207

11/96 1/97 11/97
(n=706) (n=768) (n=768)

5
(0.6%)
10
201
3
(0.4%)
100
1.1
87
(12%)

4
(0.5%)
10
301
2
(0.3%)
125
212
56
(7%)

20
67
3
(0.4%)
80
40
49
(6%)

154 164 133 143
(26%) (28%) (27%) (24%)

312
124
(19%)

From 1994 to 1997 the proportion of patients (pts) with a CD4 cell count <50//Il
decreased from 27% to 7% (p - 0.001). Also the proportion of pts with atypical
mycobacteria in the whole patient population showed an almost significant decline
(p = 0.07). However the proportion of pts with atypical mycobacteria referred to
the number of pts with a CD4+ count <50//d remained stable (7% vs. 9%).
The decrease in the incidence of Tb preceded the decline of atypical mycobacterial disease.
Conclusions: The introduction of antiretroviral combination therapy including
protease inhibitors or non- nucleoside reversetranscriptase inhibitors in 1996 is
associated with a significant decrease in severely immunocompromised pts and
pts with atypical mycobacterial disease. The decrease in pts with tuberculosis
occurred in 1995 and is not associated with a shift in the patient population
towards higher CD4+ cells.